Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Federal Programs: 93.110
Criteria: Grantor requires that the Center submit programmatic reports in accordance with the
schedules indicated in its grant agreements. Internal controls should provide for these reports to report
the measurement of the recipient's performance to show achievement of program goals and
objectives, share lessons learned, improve program outcomes, and foster adoption of promising
practices (2 CFR §200.301(a)).
Condition: During our audit, we were notified by management that certain programmatic reports were
not submitted within the deadlines outlined in the grant agreements. We also noted the Center did not
have evidence that certain programmatic reports were submitted in accordance with specific grant
terms.
Cause: The Center did not have the proper internal controls in place to ensure proper management of
the Federal award(s) in compliance with the terms and conditions of the Federal award(s).
Effect or Potential Effect: The performance progress according to the Federal award(s) may not be
monitored, thus having potential unallowable costs or unallowable activities.
Questioned Costs: None.
Context: Several programmatic reports tested were not submitted on a timely basis.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop proper internal controls to ensure appropriate
tracking of reporting deadlines for all Federal awards to ensure the preparation and timely submission
of all reports required under its Federal awards' terms and conditions.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: 93.224, 93.870
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.414 Subpart F, Appendix IV, Section C.2.f, the provisional and final rates
must be negotiated where neither predetermined nor fixed rates are appropriate. Predetermined or
fixed rates may replace provisional rates at any time prior to the close of the organization's fiscal year.
If that event does not occur, a final rate will be established and upward or downward adjustments will
be made based on the actual allowable costs incurred for the period involved.
Condition: During our review of the Center's indirect cost rate calculation, we were unable to be
provided with a true-of actual indirect costs based on the final rates versus the provisional rate used
by the Center.
Cause: The Center did not have adequate controls in place to ensure that final rates provided were
used to determine if any upward or downward adjustments were necessary.
Effect or Potential Effect: Total indirect costs charged by the Center were not in line with the final
rates as determined by the oversight agency.
Questioned Costs: None.
Context: 2 of 3 major programs tested did not have calculated indirect cost rates that agreed with
their respective agreements.
Identification as a Repeat Finding: 2021-004
Recommendation: We recommend the Center establish an internal control procedure to ensure that
once a final rate has been determined, that procedures are applied to true-up the costs for the prior
charges on grants and any upward or downward adjustments are properly recorded, reported, and
applied to future reimbursement requests.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Federal Programs: 93.110
Criteria: Grantor requires that the Center submit programmatic reports in accordance with the
schedules indicated in its grant agreements. Internal controls should provide for these reports to report
the measurement of the recipient's performance to show achievement of program goals and
objectives, share lessons learned, improve program outcomes, and foster adoption of promising
practices (2 CFR §200.301(a)).
Condition: During our audit, we were notified by management that certain programmatic reports were
not submitted within the deadlines outlined in the grant agreements. We also noted the Center did not
have evidence that certain programmatic reports were submitted in accordance with specific grant
terms.
Cause: The Center did not have the proper internal controls in place to ensure proper management of
the Federal award(s) in compliance with the terms and conditions of the Federal award(s).
Effect or Potential Effect: The performance progress according to the Federal award(s) may not be
monitored, thus having potential unallowable costs or unallowable activities.
Questioned Costs: None.
Context: Several programmatic reports tested were not submitted on a timely basis.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop proper internal controls to ensure appropriate
tracking of reporting deadlines for all Federal awards to ensure the preparation and timely submission
of all reports required under its Federal awards' terms and conditions.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.
Criteria: The Organizations are required under 2 CFR §200.302 to be able to have “identification, in
its accounts, of all Federal awards received and expended and the Federal programs under which
they were received”. It is also required to maintain “effective control over, and accountability for, all
funds, property, and other assets”. These requirements are imperative to ensure that all Federal
programs are properly reported on the Organizations’ Schedule of Expenditures of Federal Awards
(SEFA).
Condition: During our audit, we noted a few Federal programs that had expired in prior years were
inadvertently included in the SEFA by error due to failure of reallocating expenditures to the proper
Federal programs. Additionally, the Vaccines for Children program and a portion of the required
Period 4 Provider Relief Fund receipts was not included in the original SEFA prepared by the Center.
Cause: Due to significant turnover in the finance department and lack of accountability and monitoring
of Federal funds, the Center did not properly report the Federal expenditures in the SEFA. This
situation is due primarily to the fact that there is not a designated individual responsible and
accountable for ensuring that all Federal sources of funds are properly identified and monitored in
accordance with the laws and regulations, contracts, and grant agreements.
Effect or Potential Effect: Without sufficient internal controls surrounding the preparation of the
SEFA and an understanding of all programs that are Federally funded, the SEFA could be
inaccurately reported.
Questioned Costs: None.
Context: The Center failed to properly track and allocate Federal expenditures in fiscal year 2022,
which resulted in the SEFA not being properly prepared. Additionally, the Center did not have a
person with the appropriate knowledge of the Vaccines for Children program or SEFA receipt
reporting requirements of the Provider Relief Fund programs.
Identification as a Repeat Finding: Not applicable. Recommendation: We recommend the Center develop standard operating procedures (SOPs) to
document the current processes, procedures, and contingency plans to improve daily operations,
efficiency, productivity, compliance, and risk management. Additionally, we recommend that the
Center implement policies and procedures to ensure that expenses are allocated to the appropriate
Federal grant award/program so the SEFA can be prepared to accurately reflect expenses incurred.
We also recommend that the Center identify and monitor all Federal source of funds (including
Federally sourced donated vaccines) and ensure they have oversight/monitoring and are being
properly reported.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
Condition: During our audit, we noted one instance where a cash disbursement was not supported
with corroborating documentation (i.e. invoices, valuation documentation, contracts, etc.). While we
understand that this was a year of higher than normal volume of transactions for the Center, we also
recognize the importance of management’s attention to maintaining support, policies and processes
during the life cycle of an organization. Absent such documentation the Center expose themselves to
a risk of misappropriation, misclassification and questioned costs by funders.
Cause: The Center did not consistently follow the internal control policies and procedures that they
have in place to ensure each expenditure is supported with corroborating documentation.
Effect or Potential Effect: Failure to maintain proper documentation for cash disbursements, there is
a risk of misappropriation, misclassification and questioned costs by funders.
Questioned Costs: None.
Context: 1 cash disbursement tested did not have proper supporting documentation.
Identification as a Repeat Finding: 2021-003
Recommendation: In order to strengthen transparency with respect to all financial transactions, we
recommend the Center strive to ensure transactions are appropriately supported with
contemporaneous documentation justifying the nature and business purpose of each expenditure. We
also recommend the Center develop a plan to establish a system that allows for documents to be
accessed with ease, and be organized in such a manner that it allows for seamless retrieval of
documentation by those responsible for maintaining those records.
Criteria: According to 2 CFR §200.303, the non-Federal entity must: (a) Establish and maintain
effective internal control over the Federal award that provides reasonable assurance that the non-
Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and
the terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in Standards for Internal Control in the Federal Government issued by the Comptroller
General of the United States or the internal Control Integrated Framework, issued by the Committee of
Sponsoring Organizations of the Treadway Commission (COSO).
Additionally, according to 2 CFR §200.318 Procurement standards, the non-Federal entity must
maintain records sufficient to detail the history of procurement. These records will include, but are not
necessarily limited to, the following: Rationale for the method of procurement, selection of contract
type, contractor selection or rejection, and the basis for the contract price. Title 2, Subtitle A Chapter II
Part 200 Subpart D 200.319 Procurement Standards. All procurement transactions for the acquisition
of property or services required under a Federal award must be conducted in a manner providing full
and open competition consistent with the standards of this section and §200.320. The non-Federal
entity must have written procedures for procurement transactions. These procedures must ensure that
all solicitations: (1) Incorporate a clear and accurate description of the technical requirements for the
material, product, or service to be procured. Such description must not, in competitive procurements,
contain features which unduly restrict competition. The description may include a statement of the
qualitative nature of the material, product or service to be procured and, when necessary, must set
forth those minimum essential characteristics and standards to which it must conform if it is to satisfy
its intended use. Noncompetitive procurements can only be awarded in accordance with §200.320(c).
According to 2 CFR §200.320 Procurement Standards, there are specific circumstances in which
noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or
more of the following circumstances apply:
1. The acquisition of property or services, the aggregate dollar amount of which does not exceed the
micro-purchase threshold (see paragraph (a)(1) of this section);
2. The item is available only from a single source;
3. The public exigency or emergency for the requirement will not permit a delay resulting from
publicizing a competitive solicitation;
4. The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive
procurement in response to a written request from the non-Federal entity; or
5. After solicitation of a number of sources, competition is determined inadequate. Condition: During our testing over procurement, we determined that the Center did not clearly
document the rationale for the method of procurement, selection of contract type, contractor selection
or rejection, and the basis for the contract price. In addition, for noncompetitive procurements, there
was no documentation to support which of the five criteria was met to allow for the noncompetitive
procurement.
Cause: Management did not have effective internal controls in place to ensure that procurement
requirements were adequately documented and retained.
Effect or Potential Effect: Procurement records were insufficient to meet the requirements noted in
the Criteria section above, as well as the Center's internal procurement policy.
Questioned Costs: None.
Context: We noted that several items selected for testing did not document the rationale for the
method of procurement, selection of contract type, contractor selection or rejection, and the basis for
the contract price. In addition, we noted that several items selected for testing for noncompetitive
procurements did not maintain documentation of which of the five criteria were met to allow for the
noncompetitive procurement.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center retain sufficient procurement documentation to meet
the requirements noted in the Criteria section above.
Federal Programs: All
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.512(a)(1) the audit must be completed and the data collection form
described in paragraph (b) of this section and reporting package described in paragraph (c) of this
section must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s),
or nine months after the end of the audit period. If the due date falls on a Saturday, Sunday, or
Federal holiday, the reporting package is due the next business day.
Condition: The Data Collection Form for audits for each of the years ended December 31, 2021 and
December 31, 2022 were not filed timely in accordance with the requirements under Uniform
Guidance.
Cause: The Center did not have adequate controls in place to provide for a timely audit process and
allow the Data Collection Form to be filed timely.
Effect or Potential Effect: Delinquent data collection forms may result in action by funders such as 1)
draw-down restrictions, 2) reimbursable draw-down restrictions, 3) withholding a percentage of
Federal funds, 4) suspending Federal funds, or 5) termination of the award.
Questioned Costs: None.
Context: The past two years of Data Collection Forms have not been filed timely.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center establish an internal control procedure to ensure that
audits are completely more timely in the future, and within the timeframe as outlined by Uniform
Guidance, to ensure the required data collection form, along with the reporting package is filed timely.
Criteria: As stated in 2 CFR §200.303, the non-Federal entity (i.e. the Center) must establish and
maintain effective internal control over the Federal award that provides reasonable assurance that the
non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations
and terms and conditions of the Federal award. These internal controls should be in compliance with
guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller
General of the United States or in the “Internal Control Integrated Framework” issued by the
Committee of Sponsoring Organizations of the Treadway Commission (COSO).
According to 2 CFR §200.214, the non-Federal entity is subject to the non-procurement debarment
and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The
regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are
debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance
programs or activities.
Condition: During our audit, we noted several cases in which the Center did not perform, or did not
maintain proper support to demonstrate that it performed checks via SAM.gov to ensure that potential
vendors, contractors, or consultants are suspended or debarred. The failure to screen such parties
increases the possibility that U.S. Government funds may inadvertently be provided to individuals or
organizations deemed to be excluded by the U.S. Government.
Cause: Management did not have effective internal controls in place to ensure that suspension and
debarment was being performed prior to entering into contracts with vendors or contractors/
consultants.
Effect or Potential Effect: The Center is exposed to an increased risk that future noncompliance
could occur by entering into transactions with vendors, contractors, or consultants that are suspended
and debarred. Effect or Potential Effect (continued): If a non-Federal entity knowingly does business with an
excluded person, the agency responsible for the Center's funding may disallow costs, annul or
terminate the transaction, issue a stop work order, debar or suspend the non-Federal entity, or take
other remedies as appropriate.
Questioned Costs: None.
Context: The Center failed to perform and/or properly document its due diligence with respect to
these requirements. The issue is considered systemic in nature.
Identification as a Repeat Finding: Not applicable.
Recommendation: We recommend the Center implement internal controls to ensure that all vendors,
contractors, and consultants are screened for suspension and debarment prior to entering into any
executed contract. We further recommend that a policy be formalized and implemented that requires
an annual screening of any current vendors, contractors, or consultants as well.