Transparency Act Reporting; Identification of the Federal Program Federal Agency and Program Name Assistance Listing # U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA); Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC); 93.912 Award Year(s): July 1, 2023–June 30, 2025; September 1, 2023–August 31, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: During our audit, we noted six instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in the FSRS in FY 2024.
Cause: Management did not have sufficient internal controls to ensure that the required FFATA reports were submitted with all the correct information.
Effect or Potential Effect: Sanford did not submit the necessary FFATA report under the RHC project for each first-tier subaward agreement or modifications over $30,000 in FSRS and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the RHC program, there were four subrecipients that had a total of six subaward modifications in FY 2024. The six subaward modifications for which FFATA reports were not submitted totaled $388,722. Total subrecipient’s costs are $513,334 in FY 2024. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the required FFATA reports are submitted to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS.
Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported.
Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS.
Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported.
Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Activities Allowed or Unallowed, Allowable Costs/Cost Principles: Identification of the Federal Program, Federal Agency and Program Name, Assistance Listing #:U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)
Pass Through Entity:West Virginia University, University of North Dakota
R&D Cluster 93.859
Award Year(s):
February 24, 2024–May 23, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: During our audit, we noted for five milestone invoices selected for testing, Sanford did not have documented evidence of review and approval of the study activities submitted to the pass-through entity.
Cause: Management did not have sufficient internal controls to retain documentation over review and approval of milestone activities for allowability.
Effect or Potential Effect: A lack of review and approval of milestone study activities could potentially result in unallowable activities being charged to the federal program.
Questioned Costs: $0
Context: Total milestone grant amounts charged to the R&D Cluster were $390,061 in FY 2024. The total federal expenditures for the R&D Cluster for FY 2024 were $14,242,836.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management document and retain support over the review and approval of milestone study activities.
Views of Responsible Officials: As it relates to research milestone billing for the PASC grant, procedures have been revised. Upon receipt of invoice and payment from PASC, the Research Billing team will review and provide notification to the Research Director and Research Manager via email if the invoice and payment received matches to what is shown as owed in our systems.
Transparency Act Reporting; Identification of the Federal Program Federal Agency and Program Name Assistance Listing # U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA); Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC); 93.912 Award Year(s): July 1, 2023–June 30, 2025; September 1, 2023–August 31, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: During our audit, we noted six instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in the FSRS in FY 2024.
Cause: Management did not have sufficient internal controls to ensure that the required FFATA reports were submitted with all the correct information.
Effect or Potential Effect: Sanford did not submit the necessary FFATA report under the RHC project for each first-tier subaward agreement or modifications over $30,000 in FSRS and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the RHC program, there were four subrecipients that had a total of six subaward modifications in FY 2024. The six subaward modifications for which FFATA reports were not submitted totaled $388,722. Total subrecipient’s costs are $513,334 in FY 2024. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the required FFATA reports are submitted to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation
U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912
Research and Development Cluster (R&D) Various
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project)
Award Year: FY 2024 93.243
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements:
• For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services.
• Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual.
Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system.
In addition, Sanford did not require a separate individual to approve the sole source justification forms.
Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding.
Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms.
Questioned Costs: $0
Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024.
Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159.
Identification as a Repeat Finding: Partial repeat finding of 2023–001.
Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms.
Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford.
Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls.
During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November.
As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls.
To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS.
Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported.
Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services
Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”
Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov.
Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS.
Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported.
Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act.
Questioned Costs: $0
Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act.
Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Activities Allowed or Unallowed, Allowable Costs/Cost Principles: Identification of the Federal Program, Federal Agency and Program Name, Assistance Listing #:U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)
Pass Through Entity:West Virginia University, University of North Dakota
R&D Cluster 93.859
Award Year(s):
February 24, 2024–May 23, 2025
Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls 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: During our audit, we noted for five milestone invoices selected for testing, Sanford did not have documented evidence of review and approval of the study activities submitted to the pass-through entity.
Cause: Management did not have sufficient internal controls to retain documentation over review and approval of milestone activities for allowability.
Effect or Potential Effect: A lack of review and approval of milestone study activities could potentially result in unallowable activities being charged to the federal program.
Questioned Costs: $0
Context: Total milestone grant amounts charged to the R&D Cluster were $390,061 in FY 2024. The total federal expenditures for the R&D Cluster for FY 2024 were $14,242,836.
Identification as a Repeat Finding: This is not a repeat finding.
Recommendation: We recommend management document and retain support over the review and approval of milestone study activities.
Views of Responsible Officials: As it relates to research milestone billing for the PASC grant, procedures have been revised. Upon receipt of invoice and payment from PASC, the Research Billing team will review and provide notification to the Research Director and Research Manager via email if the invoice and payment received matches to what is shown as owed in our systems.