Audit 379692

FY End
2023-12-31
Total Expended
$61.42M
Findings
63
Programs
57
Year: 2023 Accepted: 2026-01-07

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
1167998 2023-001 Material Weakness Yes ABL
1167999 2023-002 Material Weakness Yes AB
1168000 2023-002 Material Weakness Yes AB
1168001 2023-002 Material Weakness Yes AB
1168002 2023-002 Material Weakness Yes AB
1168003 2023-002 Material Weakness Yes AB
1168004 2023-002 Material Weakness Yes AB
1168005 2023-002 Material Weakness Yes AB
1168006 2023-002 Material Weakness Yes AB
1168007 2023-002 Material Weakness Yes AB
1168008 2023-002 Material Weakness Yes AB
1168009 2023-002 Material Weakness Yes AB
1168010 2023-002 Material Weakness Yes AB
1168011 2023-002 Material Weakness Yes AB
1168012 2023-002 Material Weakness Yes AB
1168013 2023-002 Material Weakness Yes AB
1168014 2023-002 Material Weakness Yes AB
1168015 2023-002 Material Weakness Yes AB
1168016 2023-002 Material Weakness Yes AB
1168017 2023-002 Material Weakness Yes AB
1168018 2023-002 Material Weakness Yes AB
1168019 2023-002 Material Weakness Yes AB
1168020 2023-002 Material Weakness Yes AB
1168021 2023-002 Material Weakness Yes AB
1168022 2023-002 Material Weakness Yes AB
1168023 2023-002 Material Weakness Yes AB
1168024 2023-002 Material Weakness Yes AB
1168025 2023-002 Material Weakness Yes AB
1168026 2023-002 Material Weakness Yes AB
1168027 2023-002 Material Weakness Yes AB
1168028 2023-002 Material Weakness Yes AB
1168029 2023-002 Material Weakness Yes AB
1168030 2023-002 Material Weakness Yes AB
1168031 2023-002 Material Weakness Yes AB
1168032 2023-002 Material Weakness Yes AB
1168033 2023-002 Material Weakness Yes AB
1168034 2023-002 Material Weakness Yes AB
1168035 2023-002 Material Weakness Yes AB
1168036 2023-002 Material Weakness Yes AB
1168037 2023-002 Material Weakness Yes AB
1168038 2023-002 Material Weakness Yes AB
1168039 2023-002 Material Weakness Yes AB
1168040 2023-002 Material Weakness Yes AB
1168041 2023-002 Material Weakness Yes AB
1168042 2023-002 Material Weakness Yes AB
1168043 2023-002 Material Weakness Yes AB
1168044 2023-002 Material Weakness Yes AB
1168045 2023-002 Material Weakness Yes AB
1168046 2023-003 Material Weakness Yes P
1168047 2023-003 Material Weakness Yes P
1168048 2023-003 Material Weakness Yes P
1168049 2023-003 Material Weakness Yes P
1168050 2023-003 Material Weakness Yes P
1168051 2023-003 Material Weakness Yes P
1168052 2023-003 Material Weakness Yes P
1168053 2023-003 Material Weakness Yes P
1168054 2023-003 Material Weakness Yes P
1168055 2023-003 Material Weakness Yes P
1168056 2023-003 Material Weakness Yes P
1168057 2023-003 Material Weakness Yes P
1168058 2023-003 Material Weakness Yes P
1168059 2023-003 Material Weakness Yes P
1168060 2023-003 Material Weakness Yes P

Programs

ALN Program Spent Major Findings
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $16.29M Yes 0
93.310 TRANS-NIH RESEARCH SUPPORT $11.79M Yes 1
93.498 PROVIDER RELIEF FUND $4.01M Yes 1
93.399 CANCER CONTROL $2.67M Yes 1
93.RD COVID-19 Community Cohort $2.55M Yes 2
93.350 NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES $1.11M Yes 1
93.RD CONNECT FOR CANCER PREVENTION STUDY $972,523 Yes 2
94.006 AMERICORPS $807,289 Yes 0
93.RD VACCINE SAFETY DATALINK INFRASTRUCTURE $445,855 Yes 2
93.859 BIOMEDICAL RESEARCH AND RESEARCH TRAINING $420,352 Yes 1
93.788 OPIOID STR $402,550 Yes 0
93.RD COVID-19 VACCINES IN THE VACCINE SAFTETY DATALINK $366,174 Yes 2
16.575 CRIME VICTIM ASSISTANCE $362,684 Yes 0
32.006 COVID-19 TELEHEALTH PROGRAM $345,061 Yes 0
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $219,744 Yes 0
93.155 RURAL HEALTH RESEARCH CENTERS $195,677 Yes 0
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $151,956 Yes 1
93.RD RVTN - SENTINEL RESPIRATORY VIRUS TRANSMISSION NETWORK $151,691 Yes 2
93.866 AGING RESEARCH $138,570 Yes 1
93.393 CANCER CAUSE AND PREVENTION RESEARCH $92,847 Yes 1
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $87,410 Yes 0
93.RD FLU VACCINE TRIAL $87,286 Yes 2
10.001 AGRICULTURAL RESEARCH_BASIC AND APPLIED RESEARCH $66,822 Yes 1
93.396 CANCER BIOLOGY RESEARCH $59,748 Yes 1
10.525 FARM AND RANCH STRESS ASSISTANCE NETWORK COMPETITIVE GRANTS PROGRAM (B) $57,319 Yes 1
93.395 CANCER TREATMENT RESEARCH $52,312 Yes 1
93.RD SENTINEL $50,705 Yes 2
93.RD CARDIOVASCULAR DISEASES RESEARCH $49,688 Yes 2
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES_PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $48,822 Yes 0
93.RD VACCINE SAFETY DATALINK PROJECT, VSD COVID-19 INFRASTRUCTURE PARTICIPANTING SITE MONITORING FOR VACCINE-ASSOCIATED ENHANCED DISEASES $33,654 Yes 2
93.241 STATE RURAL HOSPITAL FLEXIBILITY PROGRAM $28,724 Yes 0
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $28,346 Yes 0
93.912 RURAL HEALTH CARE SERVICES OUTREACH, RURAL HEALTH NETWORK DEVELOPMENT AND SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT $28,243 Yes 0
93.426 IMPROVING THE HEALTH OF AMERICANS THROUGH PREVENTION AND MANAGEMENT OF DIABETES AND HEART DISEASE AND STROKE $27,044 Yes 0
93.073 BIRTH DEFECTS AND DEVELOPMENTAL DISABILITIES - PREVENTION AND SURVEILLANCE $26,401 Yes 1
93.262 OCCUPATIONAL SAFETY AND HEALTH PROGRAM $26,232 Yes 0
93.RD Optimal Strategies to Estimate the Relative Effectiveness of Influenza $25,003 Yes 2
10.212 SMALL BUSINESS INNOVATION RESEARCH $21,373 Yes 1
93.643 CHILDREN'S JUSTICE GRANTS TO STATES $10,016 Yes 0
93.435 INNOVATIVE STATE AND LOCAL PUBLIC HEALTH STRATEGIES TO PREVENT AND MANAGE DIABETES AND HEART DISEASE AND STROKE- $10,000 Yes 0
93.988 COOPERATIVE AGREEMENTS FOR STATE-BASED DIABETES CONTROL PROGRAMS AND EVALUATION OF SURVEILLANCE SYSTEMS $9,747 Yes 0
93.421 STRENGTHENING PUBLIC HEALTH SYSTEMS AND SERVICES THROUGH NATIONAL PARTNERSHIPS TO IMPROVE AND PROTECT THE NATION’S HEALTH $9,468 Yes 0
93.307 MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH $6,451 Yes 1
93.301 SMALL RURAL HOSPITAL IMPROVEMENT GRANT PROGRAM $5,950 Yes 0
93.153 COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH $5,282 Yes 1
93.837 CARDIOVASCULAR DISEASES RESEARCH $4,465 Yes 1
10.303 INTEGRATED PROGRAMS $4,416 Yes 1
93.279 DRUG ABUSE AND ADDICTION RESEARCH PROGRAMS $4,325 Yes 1
93.394 CANCER DETECTION AND DIAGNOSIS RESEARCH $2,633 Yes 1
93.575 CHILD CARE AND DEVELOPMENT BLOCK GRANT $1,326 Yes 0
93.855 ALLERGY, IMMUNOLOGY AND TRANSPLANTATION RESEARCH $1,283 Yes 1
93.RD ALLERGY AND INFECTIOUS DISEASES RESEARCH $945 Yes 2
93.211 TELEHEALTH PROGRAMS $922 Yes 0
93.RD VACCINE SAFETY DATALINK SHINGRIX PARTICIPATING SITE $351 Yes 2
93.865 CHILD HEALTH AND HUMAN DEVELOPMENT EXTRAMURAL RESEARCH $25 Yes 1
93.185 IMMUNIZATION RESEARCH, DEMONSTRATION, PUBLIC INFORMATION AND EDUCATION_TRAINING AND CLINICAL SKILLS IMPROVEMENT PROJECTS $-956 Yes 1
93.RD EVALUATING INFLUENZA AND SARSCO V-2 VACCINE EFFECTIVENESS $-5,376 Yes 2

Contacts

Name Title Type
JCALBPNMAHF3 Debra Hansen Auditee
7153879130 Norman Auditor
No contacts on file

Notes to SEFA

All federal and state grant expenditures of Marshfield Clinic Health System, Inc. and subsidiaries (the System) are included in the scope of the audit except those awarded to Family Health Center of Marshfield, Inc., an entity sponsored by the System. The audit was performed in accordance with the provisions of the OMB Uniform Guidance Compliance Supplement (Compliance Supplement) and the State Single Audit Guidance (SSAG) as issued by the State of Wisconsin Department of Administration and State Single Audit Committee. Compliance testing of all requirements, as described in the Compliance Supplement, was performed for the grant programs noted below. The Schedule of Expenditures of Federal and State Awards (Schedule) includes all federal and state grants to the System that had activity during the year ended December 31, 2023, except those awarded to Family Health Center of Marshfield, Inc. A separate audit in accordance with OMB Uniform Guidance and SSAG is completed for Family Health Center of Marshfield, Inc. Federal and state expenditures include all grants, contracts, and similar agreements entered into directly between the System and agencies and departments of the federal government and all awards to the System by other governmental entities and not-for-profit organizations pursuant to federal grants, contracts, and similar agreements. The Schedule summarizes expenditures by the following: • Major and nonmajor federal programs • Primary federal funding agency • Direct award agreements between the System and federal granting agencies • Pass-through federal award agreements between the System and nonfederal granting agencies • Direct award agreements between the System and state granting agencies • Pass-through state award agreements between the System and nonstate granting agencies Expenditures consist of direct costs and facilities and administrative costs. Direct costs are those that can be easily identified with an individual federally sponsored project. The salary of a principal investigator of a sponsored research project and the materials consumed by the project are examples of direct costs. Unlike direct costs, facilities and administrative costs cannot be easily identified with an individual sponsored project. Facilities and administrative costs are the costs of services and resources that benefit many sponsored projects as well as nonsponsored projects and activities. Expenses incurred for administration, library, building maintenance, and building and equipment depreciation are examples of facilities and administrative costs. There were no noncash expenditures or federally provided insurance related to the System’s federal or state award programs during the year ended December 31, 2023.
There were no audits of the System’s federal or state award programs performed by other organizations or grantor agencies during the year ended December 31, 2023.
All federal and state financial assistance programs are subject to review and audit by the grantor agencies. Such audits could lead to requests for reimbursements to the grantor agencies for costs disallowed under the terms of the programs. Management believes disallowances, if any, will not be material.
A subsidiary with a loan under the Community Facilities Loans and Grant program was acquired by the System on February 1, 2022. Expenditures relating to this program are reported in the Schedule as the balance as of January 1, 2023, plus any advances made from January 1, 2023 through December 31, 2023. No advances were made during 2023. The outstanding balance at December 31, 2023 was approximately $15,659,000. The loan agreements require the System to maintain certain reserve accounts. The Debt Service Reserve Account is required to be funded with an initial funding of $500,000 and annual contributions of $200,000 until the balance reaches $1,500,000. At December 31, 2023, the balance was $900,000. There is also a requirement to establish a Repair, Replacement and Improvement reserve in the amount of $20,000 per year. At December 31, 2023, the balance was $60,000. These accounts are included in assets whose use is limited or restricted on the consolidated balance sheet of the System’s consolidated financial statements. The loan agreements also require the System satisfy certain measures of financial performance starting with the year ended December 31, 2022. Scheduled principal and interest payments on this long-term debt are as follows: Year Ending December 31, Principal, Interest, Total 2024 $544,159 $334,300 $878,462 2025 555,722 322,740 878,462 2026 567,531 310,931 878,462 2027 579,591 298,871 878,462 2028 591,908 286,554 878,462 Thereafter 12,820,089 2,724,648 15,544,737 Total $15,659,000 $4,278,047 $19,937,047
The categorization of expenditures by program included in the schedule of expenditures of federal and state awards is based upon the grant documents. Changes in the categorization of expenditures occur based upon revisions to the Assistance Listing, which is issued in June and December of each year. The schedule of expenditures of federal awards for the year ended December 31, 2023 reflects Assistance Listing changes through May 2023.
The System’s settlement of DHS cost reimbursement awards presented for the year ended December 31, 2023 are summarized below. Certain awards summarized below may not agree to the amounts in the Schedule based on the difference of timing of reporting to DHS and the recognition of expenses on the Schedule. The indirect costs represent facilities and administrative costs allocated to the program based on a predetermined indirect cost rate negotiated with the U.S. Department of Health and Human Services. Grant Enrollment, Application and Reporting (GEARS) System Award Title Award Amount Award Period Period of award within audit period Expenditures reported to GEARS for payment Salary and wages Other expenses Indirect costs Total allowable costs 533187 Alliance WI PREV SOR 2 $ 439,057 9/30/22-9/29/23 1/1/23-9/29/23 $ 402,550 $ 48,410 $ 287,048 $ 67,092 $ 402,550 533016 Alliance WI YTH $ 337,838 7/1/21-6/30/22 N/A (1,950) - (1,650) (300) (1,950) 533016 Alliance WI YTH $ 231,838 7/1/22-6/30/23 1/1/23-6/30/23 131,743 73,213 36,671 21,859 131,743 533016 Alliance WI YTH $ 241,838 7/1/23-6/30/24 7/1/23-12/31/23 89,951 63,765 11,207 14,979 89,951 155795 Allied Health Professionals $ 125,000 7/1/23-6/30/24 7/1/23-12/31/23 69,832 - 69,832 - 69,832 128010 Congenital Disorders Program $ 37,546 7/1/21-6/30/22 N/A (110) (92) - (18) (110) 128010 Congenital Disorders Program $ 37,546 7/1/22-6/30/23 1/1/23-6/30/23 15,090 12,575 - 2,515 15,090 128010 Congenital Disorders Program $ 37,546 7/1/23-6/30/24 7/1/23-12/31/23 15,537 12,948 - 2,589 15,537 128011 Congenital Disorders PROD $ 136,725 7/1/22-6/30/23 1/1/23-6/30/23 55,521 - 46,267 9,254 55,521 128011 Congenital Disorders Special D $ 136,725 7/1/23-6/30/24 7/1/23-12/31/23 46,794 - 38,995 7,799 46,794 157010 WWWP GPR EDU AND MJA $ 86,447 7/1/22-6/30/23 1/1/23-6/30/23 27,498 27,498 - - 27,498 157120 WWWP-NBCCEDP $ 11,370 7/1/22-6/30/23 1/1/23-6/30/23 848 521 327 - 848 $ 853,304 $ 238,838 $ 488,697 $ 125,769 $ 853,304
The schedule of expenditures of federal and state awards has been restated to include additional federal expenditures of $4,801,975 related to the research and development cluster major program. These expenditures were inadvertently omitted from the previously issued schedule of expenditures of federal and state awards. The total research and development cluster federal expenditures as previously reported of $18,938,015 has been restated to $23,739,990. Total expenditures of federal awards of $56,622,289 as previously reported has been restated to $61,424,264.

Finding Details

Finding 2023-001 – Allowable Costs and Reporting U.S. Department of Health and Human Services COVID-19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing # 93.498 Significant Deficiency and Allowable Costs Noncompliance Criteria – 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition – During our testing of compliance and internal controls over allowability of costs and reporting of expenditures, it was determined that internal controls over reporting are not designed to prevent and detect errors in expenditures being reported on the Department of Health Resources and Services Administration (HRSA) portal (Portal). Consequently, we noted approximately $49,000 of ineligible expenditures related to employee testing were submitted on the Portal for period 5. Cause – Lack of effectively designed and implemented internal controls over allowability of expenditures and reporting of expenditures in the Portal for period 5. Effect – Without the proper implementation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect noncompliance. Questioned costs – $49,000. Context – Our testing noted approximately $49,000 of ineligible expenditures for employee testing out of a total of approximately $167,000 in expenditures that were reported on the Portal for period 5. Our sample was not intended to be statistically valid. Repeat Finding from Prior Year – Yes. See item 2022-004. Recommendation – Effective supervisory review and approval internal controls over reporting should be implemented to ensure expenditures submitted in the Portal meet the criteria established in the terms and conditions. Furthermore, the review and approval should be formally documented.
Finding 2023-002 – Allowable Costs Research and Development Cluster Significant Deficiency Criteria – 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition – During our testing of internal controls over allowability of costs, it was determined that internal controls over allowable costs are not designed to prevent and detect errors in employee reimbursed expenditures being reported on certain Group 1 benefited employees’ expense reports for amounts charged to research and development programs. Cause – Lack of effectively designed and implemented internal controls over allowability of expenditures. Effect – Without the proper implementation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect noncompliance. Context – Our testing noted one transaction out of a total of 40 transactions that did not have documentation of appropriate approval. Our sample was not intended to be statistically valid. Repeat Finding from Prior Year – No. Recommendation – Effective supervisory review and approval internal controls over employee expense reimbursements should be implemented to ensure expenditures charged to federal or state awards meet the criteria established in the terms and conditions. Furthermore, the review and approval should be formally documented.
Finding 2023-003 – Preparation of the Schedule of Expenditures of Federal Awards U.S. Department of Health and Human Services U.S. Department of Agriculture Research and Development (R&D) Cluster Material Weakness Criteria – Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires the System to prepare a schedule of expenditures of federal awards. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition – Inadequate controls exist over the preparation of the Schedule of Expenditures of Federal and State Awards (the Schedule) specific to research and development (R&D) cluster awards to allow for the timely completion of a complete and accurate Schedule. Consequently, certain R&D cluster expenditures were inadvertently omitted from the previously issued Schedule. Cause – The System did not have adequate controls over identifying all R&D cost reimbursement Federal Acquisition Regulation (FAR) contract related expenditures that should be reported on the Schedule. Effect – Management identified additional reportable R&D cost reimbursement FAR contract related expenditures that were added to the restated Schedule. Questioned Costs – None reported. Context – Approximately $4,800,000 of additional R&D expenditures under cost reimbursement FAR contracts in relation to the restated total expenditures of approximately $23,739,000 under the R&D cluster for the year-ended December 31, 2023, were omitted from the previously issued Schedule. Repeat Finding from Prior Year – No. Recommendation – We recommend that management enhance its controls over the Schedule to ensure they include all R&D expenditures to facilitate timely, accurate completion of the Schedule.