Audit 360649

Finding 2024-001 Federal Funding Accountability and Transparency Act (FFATA) Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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 testing of FFATA Report, it was identified that the report was not submitted by Fairview management within the time frame designated in 2 CFR 170 Appendix A. Cause: Policies and procedures and internal controls were not in place to ensure compliance with the FFATA reporting requirements. Effect or potential effect: Fairview Health Services did not report the necessary FFATA report for first-tier subawards over $30,000 to the FFATA Subaward Reporting System. Questioned costs: None. Context: Total subrecipient expenditures subject to FFATA reporting were $155,996 for the year ended December 31, 2024 and total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: We recommend that Fairview Health Services management take immediate action to ensure compliance with the reporting requirements of the FFATA. Views of responsible officials: Management agrees with the finding. The FFATA report was filed on April 15, 2025. Fairview has established an internal control to ensure timely filing of FFATA reports in the future.

Finding 2024-002 Procurement and Suspension and Debarment Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000–$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: For one procurement transaction tested, we noted that Fairview Health Services did not complete a sole-source justification form timely to support the vendor that was selected. Cause: Management does not have sufficient internal controls in place to ensure that Fairview Health Services’ procurement policies are followed for all procurement transactions prior to entering the procurement. Effect or potential effect: Fairview Health Services entered into a procurement that did not go through a competitive solicitation process. Questioned costs: None Context: Total Federal expenditures subject to procurement for HPP were $616,107 for the year ended December 31, 2024. Total expenditures related to the procurement at issue were $29,041. Total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should review its policies and procedures to ensure all procurement transactions are in accordance with Fairview Health Services’ procurement policies and have the appropriate supporting documentation. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.

Finding 2024-003 Procurement and Suspension and Debarment Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000-$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: The data used in evaluating the vendors for suspension and debarment was not reviewed and approved. Cause: Management does not have internal controls in place to require the review and approval of the data used in evaluation of vendors for suspension and debarment. Effect or potential effect: Suspension and debarment results may not be accurate. As a result, federal funds may be used to pay a contractor that is suspended or debarred. Questioned costs: None Context: Total Federal expenditures subject to suspension and debarment were $947,686, representing 57% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls over the review and approval of the data used in suspension and debarment analysis. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.

Finding 2024-004 Internal Controls over Allowability Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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: Fairview management did not retain documentation of review and approval of the fringe benefit rate calculation. In addition, Fairview management did not retain documentation of review and approval of supplies expenses for allowability. Cause: Fairview Health Services did not have internal controls in place that require supporting documentation of review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Effect or potential effect: Expenses may be charged to the federal award that are not in compliance with the federal grant agreements. Questioned costs: None. Context: For Assistance Listing No. 93.817, total fringe benefit expenses were $104,506, representing 6% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. For Assistance Listing No. 93.817, total supplies expenses were $85,328, representing 5% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should enhance internal controls to require the review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.

Finding 2024-001 Federal Funding Accountability and Transparency Act (FFATA) Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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 testing of FFATA Report, it was identified that the report was not submitted by Fairview management within the time frame designated in 2 CFR 170 Appendix A. Cause: Policies and procedures and internal controls were not in place to ensure compliance with the FFATA reporting requirements. Effect or potential effect: Fairview Health Services did not report the necessary FFATA report for first-tier subawards over $30,000 to the FFATA Subaward Reporting System. Questioned costs: None. Context: Total subrecipient expenditures subject to FFATA reporting were $155,996 for the year ended December 31, 2024 and total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: We recommend that Fairview Health Services management take immediate action to ensure compliance with the reporting requirements of the FFATA. Views of responsible officials: Management agrees with the finding. The FFATA report was filed on April 15, 2025. Fairview has established an internal control to ensure timely filing of FFATA reports in the future.

Finding 2024-002 Procurement and Suspension and Debarment Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000–$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: For one procurement transaction tested, we noted that Fairview Health Services did not complete a sole-source justification form timely to support the vendor that was selected. Cause: Management does not have sufficient internal controls in place to ensure that Fairview Health Services’ procurement policies are followed for all procurement transactions prior to entering the procurement. Effect or potential effect: Fairview Health Services entered into a procurement that did not go through a competitive solicitation process. Questioned costs: None Context: Total Federal expenditures subject to procurement for HPP were $616,107 for the year ended December 31, 2024. Total expenditures related to the procurement at issue were $29,041. Total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should review its policies and procedures to ensure all procurement transactions are in accordance with Fairview Health Services’ procurement policies and have the appropriate supporting documentation. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.

Finding 2024-003 Procurement and Suspension and Debarment Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000-$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: The data used in evaluating the vendors for suspension and debarment was not reviewed and approved. Cause: Management does not have internal controls in place to require the review and approval of the data used in evaluation of vendors for suspension and debarment. Effect or potential effect: Suspension and debarment results may not be accurate. As a result, federal funds may be used to pay a contractor that is suspended or debarred. Questioned costs: None Context: Total Federal expenditures subject to suspension and debarment were $947,686, representing 57% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls over the review and approval of the data used in suspension and debarment analysis. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.

Finding 2024-004 Internal Controls over Allowability Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities 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: Fairview management did not retain documentation of review and approval of the fringe benefit rate calculation. In addition, Fairview management did not retain documentation of review and approval of supplies expenses for allowability. Cause: Fairview Health Services did not have internal controls in place that require supporting documentation of review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Effect or potential effect: Expenses may be charged to the federal award that are not in compliance with the federal grant agreements. Questioned costs: None. Context: For Assistance Listing No. 93.817, total fringe benefit expenses were $104,506, representing 6% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. For Assistance Listing No. 93.817, total supplies expenses were $85,328, representing 5% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should enhance internal controls to require the review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.