Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Criteria To be eligible under the Substance Use Disorder Treatment and Recovery Support Services award, a patient must 1) have income below 400% of the federal poverty level, 2) be a resident of New Hampshire or experiencing homelessness in New Hampshire, and 3) be determined positive for substance use disorder. Additionally, patient income information for all eligible patients receiving services must be updated at a minimum interval of once every four weeks. Condition Cheshire Medical Center operates The Doorway program in Keene, NH. The Doorway connects patients positive for substance use disorder with support services and treatment, and receives a portion of its funding from the Substance Use Disorder Treatment and Recovery Support Services federal award. Through our testing of eligibility requirements for 25 patients, we noted the following: ? For all selections, no formal documentation was maintained regarding patient income levels. ? For all selections, income reassessments were not completed and documented at least once every four weeks. ? One selected patient was neither a resident of New Hampshire, nor experiencing homelessness in New Hampshire. While The Doorway provides services to patients beyond those defined as eligible under the Substance Use Disorder Treatment and Recovery Support Services award, there is no differentiation between patients that are eligible or ineligible under the federal program. As a result of patients not being differentiated, time and effort incurred by personnel on the award is commingled with non-award activity. For example, a clinician?s salary is funded under the award, but she is not seeing only eligible patients. As such, any time she spent treating a patient who is not eligible would be a questioned cost under the grant. Cause The nature and purpose of the federal program is very similar and consistent with the mission and operations of The Doorway. Management did not understand the need to differentiate the services performed and patients served in order to demonstrate compliance with award terms and conditions. Effect The commingling of activities between federal and non-federal programs does not allow for compliance with award specific terms and conditions and with eligibility requirements to be effectively managed. Questioned Costs We were unable to verify eligibility requirements were met for the program which had total expenditures of $838,932. Recommendation We recommend that internal controls and policies be implemented to manage the eligibility requirements of the federal awards and ensure that documentation to support eligibility determinations is maintained. Further, procedures to differentiate patients eligible under the award from those determined to beineligible, along with a mechanism to track the time and expenses associated with eligible patients should be put in place. Management?s View and Corrective Action Plan Management's views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: Department of Health and Human Services, Department of Defense Award Names: First-in-human clinical translation of a near-infrared, nerve-specific fluorophore to facilitate tissue-specific fluorescence-guided surgery; Self-Administered, Motor-Free, Cognitive Screening Battery for MS: Development and Initial Validation; Decision Making in Transmasculine Genital Reconstruction Surgery (TMGRS) Award Numbers: 1R01NS116994-01A1; W81XWH2010330; R21DK124733 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development; Diabetes, Digestive, and Kidney Diseases Extramural Research Assistance Listing Number: 93.853; 12.420; 93.847 Award Year: 2021 - 2022 Pass-through entity: Not applicable Criteria The Health System has a policy whereby purchases shall comply with Uniform Guidance for Grants and Cooperative agreements, as established in 2 CFR 200.320 Methods of Procurement to be followed and they have adopted $10,000 as their micro-purchase threshold. 2 CFR 200.318 requires that documentation of the history of the procurement, the procurement method and rationale for the method selected, selection of contract type, basis for contractor selection, and basis for the contract price to be included in the procurement file. Additionally, a non-Federal entity must have and use documented procurement procedures and is prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting a certification from the entity, or (3) adding a clause or condition to the covered transaction with that entity (2 CFR section 180.300). The Health System?s suspension and debarment policy requires suspension and debarment verifications to be completed for all vendors utilized on federal awards, regardless of expenditure amount. Condition As part of the Research and Development cluster procurement testing of new purchases greater than $10,000 there were 4 transactions selected for testing out of a population of 21 transactions totaling $481,000. We noted two transactions of $69,500 and $12,000 where there was no documentation of the vendor justification, but were determined to be sole source. Management was able to provide us with an understanding of why the vendor was selected; however, this sole source justification was not documented in the procurement files. Additionally, as part of the testing over compliance with the Health System?s suspension and debarment verification policy, we noted one vendor with expenditures of $1,400 where the suspension and debarment verification was not performed in advance of paying the related invoice. We received evidence of the suspension and debarment verification completed after invoice payment, where no exclusions were identified. Cause While the procurement policy outlines the procedures to be followed for federal purchases, there is no formal review to ensure all federal documentation requirements related to purchases above the micropurchase threshold have been included in the procurement files. Additionally, there is no formal review to ensure that suspension and debarment verifications have been completed for all vendors prior to invoice payment. Effect The lack of adherence to established policies for bidding documentation and sole source justification and a formal process for review could result in competition being inappropriately limited. The lack adherence to the suspension and debarment verification policy could result in the Health System conducting business with a vendor that is suspended or debarred. Questioned Costs None noted. Recommendation We recommend the Health System formalize the documentation and review required for procurements over the micro-purchase threshold, including review of multiple vendor quotations or sole source justification documentation prior to the purchase being made. Additionally, the Health System should ensure that timely suspension and debarment verifications are completed in line with policy. Management?s View and Corrective Action Plan Management?s views and corrective action plan are included at the end of this report after the summary of status of prior audit findings
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Criteria To be eligible under the Substance Use Disorder Treatment and Recovery Support Services award, a patient must 1) have income below 400% of the federal poverty level, 2) be a resident of New Hampshire or experiencing homelessness in New Hampshire, and 3) be determined positive for substance use disorder. Additionally, patient income information for all eligible patients receiving services must be updated at a minimum interval of once every four weeks. Condition Cheshire Medical Center operates The Doorway program in Keene, NH. The Doorway connects patients positive for substance use disorder with support services and treatment, and receives a portion of its funding from the Substance Use Disorder Treatment and Recovery Support Services federal award. Through our testing of eligibility requirements for 25 patients, we noted the following: ? For all selections, no formal documentation was maintained regarding patient income levels. ? For all selections, income reassessments were not completed and documented at least once every four weeks. ? One selected patient was neither a resident of New Hampshire, nor experiencing homelessness in New Hampshire. While The Doorway provides services to patients beyond those defined as eligible under the Substance Use Disorder Treatment and Recovery Support Services award, there is no differentiation between patients that are eligible or ineligible under the federal program. As a result of patients not being differentiated, time and effort incurred by personnel on the award is commingled with non-award activity. For example, a clinician?s salary is funded under the award, but she is not seeing only eligible patients. As such, any time she spent treating a patient who is not eligible would be a questioned cost under the grant. Cause The nature and purpose of the federal program is very similar and consistent with the mission and operations of The Doorway. Management did not understand the need to differentiate the services performed and patients served in order to demonstrate compliance with award terms and conditions. Effect The commingling of activities between federal and non-federal programs does not allow for compliance with award specific terms and conditions and with eligibility requirements to be effectively managed. Questioned Costs We were unable to verify eligibility requirements were met for the program which had total expenditures of $838,932. Recommendation We recommend that internal controls and policies be implemented to manage the eligibility requirements of the federal awards and ensure that documentation to support eligibility determinations is maintained. Further, procedures to differentiate patients eligible under the award from those determined to beineligible, along with a mechanism to track the time and expenses associated with eligible patients should be put in place. Management?s View and Corrective Action Plan Management's views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Criteria 2 CFR 200.332 notes that pass-through entity monitoring of the subrecipient must include: 1. Reviewing financial and performance reports required by the pass-through entity. 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the particular subaward. 3. Issuing a management decision for applicable audit findings pertaining only to the Federal award provided to the subrecipient from the pass-through entity as required by 2 CFR 200.521. Further, Uniform Guidance 2 CFR section 200.331(f) requires that the entity verify that every subrecipient is audited as required by Subpart F? Audit Requirements when it is expected that the subrecipient?s Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in ?200.501 Audit requirements ($750,000). Condition In testing conformity with the compliance requirements for subrecipient monitoring, we selected 7 of the 61 Research and Development subrecipient agreements and the one Opioid STR subrecipient agreement from the detailed listings provided for testing. The total federal funds passed through to subrecipients in FY22 amounted to $3.5 million for the Research & Development Cluster, and $24,500 for the Opioid STR program. For all of our selections, the most recent audit report was not reviewed for purposes of ongoing monitoring as required by the Uniform Guidance. The Health System has a risk assessment form that is completed at contract inception for its subrecipients; however, the risk assessment is not reassessed annually for all subrecipients. The most recent risk assessment form was conducted in 2018 for 2 selections, in 2019 for 2 selections, in 2020 for 2 selections and in 2021 for 2 selections. We further noted that 7 of the 8 risk assessment forms selected for testing did not include explicit documentation detailing the subrecipient audit report review (such as what year was reviewed, what were the results of the review, etc.). Additionally, for one selection, the initial subrecipient risk assessment form was reviewed after the subrecipient award agreement was executed. Cause The Health System?s subrecipient policy does not explicitly state the ongoing monitoring activities that must be conducted or the frequency of required monitoring. For instance, the policy does not outlinemonitoring activities that are required for all subrecipients. Additionally, the risk assessment form does not prescribe the details of the subrecipient audit report review that should be documented. Effect The subrecipients of the Health System may have audit findings pertaining to the Federal award provided from the Health System that may have implications on the compliance of the Health System with Uniform Guidance. Additionally, there may be changes in the risk characteristics of subrecipients that are not identified if risk assessments are not periodically updated. Questioned Costs None noted. Recommendation We recommend that he Health System update its subrecipient monitoring policy to reflect all monitoring compliance requirements of the Uniform Guidance. In particular, the policy should require the receipt of the Uniform Guidance report from all subrecipients that expended $750,000 or more in federal awards during the subrecipient?s fiscal year (or the receipt of the subrecipient?s latest financial statements if not) at contract inception. Any audit findings pertaining to the Federal award should be followed up on by the Health System and a management decision should be issued. This Policy should be distributed and adhered to by all that have a role in the subrecipient monitoring process of the Health System. Management?s Views and Corrective Action Plan Management?s response is included in ?Management?s Views and Corrective Action Plan? included at the end of this report after the summary schedule of status of prior audit findings.
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status
Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status