Audit 55776

FY End
2022-12-31
Total Expended
$80.98M
Findings
52
Programs
31
Organization: Advocate Aurora Health, Inc. (IL)
Year: 2022 Accepted: 2023-09-28

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
59655 2022-001 Material Weakness - AB
59656 2022-001 Material Weakness Yes AB
59657 2022-001 Material Weakness Yes AB
59658 2022-001 Material Weakness Yes AB
59659 2022-001 Material Weakness Yes AB
59660 2022-001 Material Weakness Yes AB
59661 2022-001 Material Weakness Yes AB
59662 2022-001 Material Weakness Yes AB
59663 2022-001 Material Weakness Yes AB
59664 2022-001 Material Weakness Yes AB
59665 2022-001 Material Weakness Yes AB
59666 2022-001 Material Weakness Yes AB
59667 2022-001 Material Weakness Yes AB
59668 2022-001 Material Weakness Yes AB
59669 2022-001 Material Weakness Yes AB
59670 2022-002 Material Weakness - ABN
59671 2022-001 Material Weakness Yes AB
59672 2022-001 Material Weakness Yes AB
59673 2022-001 Material Weakness Yes AB
59674 2022-001 Material Weakness Yes AB
59675 2022-001 Material Weakness Yes AB
59676 2022-001 Material Weakness Yes AB
59677 2022-001 Material Weakness Yes AB
59678 2022-001 Material Weakness Yes AB
59679 2022-001 Material Weakness Yes AB
59680 2022-001 Material Weakness Yes AB
636097 2022-001 Material Weakness - AB
636098 2022-001 Material Weakness Yes AB
636099 2022-001 Material Weakness Yes AB
636100 2022-001 Material Weakness Yes AB
636101 2022-001 Material Weakness Yes AB
636102 2022-001 Material Weakness Yes AB
636103 2022-001 Material Weakness Yes AB
636104 2022-001 Material Weakness Yes AB
636105 2022-001 Material Weakness Yes AB
636106 2022-001 Material Weakness Yes AB
636107 2022-001 Material Weakness Yes AB
636108 2022-001 Material Weakness Yes AB
636109 2022-001 Material Weakness Yes AB
636110 2022-001 Material Weakness Yes AB
636111 2022-001 Material Weakness Yes AB
636112 2022-002 Material Weakness - ABN
636113 2022-001 Material Weakness Yes AB
636114 2022-001 Material Weakness Yes AB
636115 2022-001 Material Weakness Yes AB
636116 2022-001 Material Weakness Yes AB
636117 2022-001 Material Weakness Yes AB
636118 2022-001 Material Weakness Yes AB
636119 2022-001 Material Weakness Yes AB
636120 2022-001 Material Weakness Yes AB
636121 2022-001 Material Weakness Yes AB
636122 2022-001 Material Weakness Yes AB

Programs

ALN Program Spent Major Findings
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $35.51M Yes 1
93.498 Covid-19 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $34.35M Yes 0
93.788 Opioid Str $747,335 - 0
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $588,032 - 0
21.027 Coronavirus State and Local Fiscal Recovery Funds $377,602 - 0
93.959 Block Grants for Prevention and Treatment of Substance Abuse $285,068 - 0
93.889 National Bioterrorism Hospital Preparedness Program $241,700 - 0
93.866 Aging Research $198,004 Yes 1
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $166,501 - 0
16.575 Crime Victim Assistance $159,830 - 0
93.958 Block Grants for Community Mental Health Services $133,506 - 0
93.307 Minority Health and Health Disparities Research $122,925 Yes 1
93.421 Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nations Health $94,000 - 0
93.242 Mental Health Research Grants $89,204 Yes 1
93.399 Cancer Control $52,007 Yes 1
93.136 Injury Prevention and Control Research and State and Community Based Programs $40,694 - 0
93.865 Child Health and Human Development Extramural Research $34,897 Yes 1
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $30,360 - 0
93.074 Hospital Preparedness Program (hpp) and Public Health Emergency Preparedness (phep) Aligned Cooperative Agreements $26,925 - 0
93.279 Drug Abuse and Addiction Research Programs $22,704 Yes 1
93.393 Cancer Cause and Prevention Research $19,059 Yes 1
20.600 State and Community Highway Safety $17,539 - 0
93.566 Refugee and Entrant Assistance_state Administered Programs $16,062 - 0
16.754 Harold Rogers Prescription Drug Monitoring Program $9,151 - 0
93.226 Research on Healthcare Costs, Quality and Outcomes $8,776 Yes 1
93.497 Family Violence Prevention and Services/ Sexual Assault/rape Crisis Services and Supports $8,191 - 0
93.086 Healthy Marriage Promotion and Responsible Fatherhood Grants $6,616 Yes 1
93.837 Cardiovascular Diseases Research $5,700 Yes 1
10.555 National School Lunch Program $5,562 - 0
10.558 Child and Adult Care Food Program $1,272 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $479 Yes 1

Contacts

Name Title Type
HC33WK5N73M3 Rachel Halverson Auditee
4142991862 Maureen Wood Auditor
No contacts on file

Notes to SEFA

Title: Contracted Service Revenue Accounting Policies: The accompanying Schedules of Expenditures of Federal and State of Wisconsin Awards (the Schedules) summarize expenditures charged to federal and state funded grants and service contracts administered by Advocate Aurora Health, Inc. (the Organization) for the year ended December 31, 2022. The Schedules should be read in conjunction with the consolidated financial statements of the Organization and are presented on the accrual basis of accounting. See Note 1 of the consolidated financial statements of the Organization for a description of the reporting entity. The expenditures listed in the Schedules are subject to the provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the Wisconsin State Single Audit Guidelines. For purposes of the Schedules, federal and state awards include all grants, service contracts, and similar agreements entered into directly between the Organization and agencies and departments of the federal government and the state of Wisconsin, and all awards to the Organization by other governmental entities and not-for-profit organizations pursuant to federal and state of Wisconsin grants, contracts, and similar agreements. Expenditures of federal and state awards are to be used for the purposes specified by the funding source and are recognized when allowable and reimbursable costs (including direct and indirect costs) are incurred in compliance with the legal or contractual requirements of the funding source. De Minimis Rate Used: N Rate Explanation: The Organization did not elect to use the de minimis indirect cost rate as allowed under the Uniform Guidance. The expenditures listed in the Schedule constitute grant awards and are subject to the provisions of Uniform Grant Guidance and the Wisconsin State Single Audit Guidelines. The agency also receives contracted service revenue from the following agencies for the following programs in the amounts listed. Contracted service revenue is not disclosed in the Schedules, but Wisconsin State Single Audit Guidelines require this funding source to be disclosed. The Organization received contracted service revenue from the following State of Wisconsin agencies and programs for the year ended December 31, 2022. See the Notes to the SEFA for chart/table.
Title: COVID-19 Provider Relief Fund (Assistance Listing No. 93.498) Accounting Policies: The accompanying Schedules of Expenditures of Federal and State of Wisconsin Awards (the Schedules) summarize expenditures charged to federal and state funded grants and service contracts administered by Advocate Aurora Health, Inc. (the Organization) for the year ended December 31, 2022. The Schedules should be read in conjunction with the consolidated financial statements of the Organization and are presented on the accrual basis of accounting. See Note 1 of the consolidated financial statements of the Organization for a description of the reporting entity. The expenditures listed in the Schedules are subject to the provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the Wisconsin State Single Audit Guidelines. For purposes of the Schedules, federal and state awards include all grants, service contracts, and similar agreements entered into directly between the Organization and agencies and departments of the federal government and the state of Wisconsin, and all awards to the Organization by other governmental entities and not-for-profit organizations pursuant to federal and state of Wisconsin grants, contracts, and similar agreements. Expenditures of federal and state awards are to be used for the purposes specified by the funding source and are recognized when allowable and reimbursable costs (including direct and indirect costs) are incurred in compliance with the legal or contractual requirements of the funding source. De Minimis Rate Used: N Rate Explanation: The Organization did not elect to use the de minimis indirect cost rate as allowed under the Uniform Guidance. The Schedule includes $34,353,988 received from the U.S. Department of Health and Human Services (HHS) between January 1, 2021 through December 31, 2021 under the COVID-19 Provider Relief Fund (PRF) Assistance Listing No. 93.498. In accordance with guidance from HHS, these amounts are presented as Period 3 and Period 4 in the HHS PRF Reporting Portal. Such amounts were recognized as other revenue in the Organizations consolidated financial statements in the consolidated statements of operations and changes in net assets for the years ended December 31, 2022 and 2021. Due to the PRF Reporting Portal requirements, this amount is not the total PRF received and/or recognized by the Organization as other revenues in the Organizations consolidated financial statements for the year ended December 31, 2021. The amount presented on the Schedule for PRF is for the fiscal year ended December 31, 2022. See the Notes to the SEFA for chart/table.
Title: Disaster Grants Public Assistance (Presidentially Declared Disasters) Accounting Policies: The accompanying Schedules of Expenditures of Federal and State of Wisconsin Awards (the Schedules) summarize expenditures charged to federal and state funded grants and service contracts administered by Advocate Aurora Health, Inc. (the Organization) for the year ended December 31, 2022. The Schedules should be read in conjunction with the consolidated financial statements of the Organization and are presented on the accrual basis of accounting. See Note 1 of the consolidated financial statements of the Organization for a description of the reporting entity. The expenditures listed in the Schedules are subject to the provisions of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the Wisconsin State Single Audit Guidelines. For purposes of the Schedules, federal and state awards include all grants, service contracts, and similar agreements entered into directly between the Organization and agencies and departments of the federal government and the state of Wisconsin, and all awards to the Organization by other governmental entities and not-for-profit organizations pursuant to federal and state of Wisconsin grants, contracts, and similar agreements. Expenditures of federal and state awards are to be used for the purposes specified by the funding source and are recognized when allowable and reimbursable costs (including direct and indirect costs) are incurred in compliance with the legal or contractual requirements of the funding source. De Minimis Rate Used: N Rate Explanation: The Organization did not elect to use the de minimis indirect cost rate as allowed under the Uniform Guidance. The Organization incurred expenditures in fiscal years 2020 and 2021 related to 1 project worksheet; however, FEMA did not obligate the project worksheet until fiscal year 2022. As a result, all Assistance Listing Number 97.036 federal expenditures reported in the Schedule for the year ended December 31, 2022 were incurred in prior years.

Finding Details

Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-002 Information on the Federal Program: Federal Agency: Department of Homeland Security Assistance Listing No.: 97.036 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through: Illinois State Department of Health Pass-Through Award Number: PA-05-IL-4489-PW-01416(1753) Section III ? Federal Award Findings and Questioned Costs (continued) Pass-Through Award Period of Performance: January 20, 2020 through December 31, 2021 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?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).? Per the FEMA Project Worksheet Report #664845, under the Subgrant Conditions section, bullet point 1, ?As described in Title 2 Code of Federal Regulations (C.F.R.) ? 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.? Condition: The Organization?s internal controls were not suitably designed to retain all supporting documentation over their review and approval of FEMA federal expenditures. Management did not retain supporting documentation to support the inventory usage reports used in the development of the FEMA expenditures. Cause: Management designed a process to accumulate and review expenditures related to the FEMA; however, for certain components of the review and approval the supporting documentation was not retained to evidence that the internal review was sufficiently designed and operating effectively throughout the process. Section III ? Federal Award Findings and Questioned Costs (continued) Management did not retain supporting documentation to support the inventory usage reports used in the development of the FEMA expenditures. Questioned Costs: Unknown Context: The Organization recorded FEMA expenditures on the Schedule based on the number of units of the personal protective equipment (PPE) used during the period of performance outlined in the project worksheet times the average costs of each unit of PPE. The information used to develop the FEMA expenditures was obtained from the Organization?s inventory management system. Management did not retain supporting documentation to support the reliance on the inventory usage reports; therefore, the information from the inventory management system cannot be relied on for Uniform Guidance purposes. Management represented that they performed a review of FEMA expenditures but did not maintain evidence supporting all levels of review and approval of expenses under FEMA. We obtained the Organization?s FEMA project worksheet that reconciled to the schedule of expenditures of federal awards. We then selected a sample of 25 PPE items and agreed the items used and the average unit costs to the inventory management system. In addition, we compared the average unit cost to a third-party invoice to support the unit cost used. Management engaged a third party to perform a physical inventory of supplies at December 31, 2020 which included the PPE claimed in the SEFA obligation. The physical inventory was reconciled to the inventory management system. We selected a sample of inventory counts performed by the third-party agency and agreed the inventory counts back to the third-party records, noting no exceptions. A physical inventory was not performed at December 31, 2021. Total federal expenditures for Assistance Listing 97.036 recorded on the Schedule totaled $35,508,438 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Effect or Potential Effect: The amounts submitted for reimbursement and the reports submitted could be inaccurate or incomplete. Identification as a Repeat Finding, if Applicable: This is not a repeat finding. Recommendation: The Organization should design and implement internal controls that are sufficiently precise and require supporting documentation be retained over the review and approval of FEMA expenses. The Organization should retain evidence of internal controls related to access and change management over the report or a quality review process over the inventory reports. Management response: The FEMA personal protective equipment (PPE) claim covered two years, which are 2020 and 2021. As noted in the audit, the Organization engaged a third party to perform a physical inventory of supplies at December 31, 2020 which included the PPE claimed in the SEFA obligation. The physical inventory was reconciled to the inventory management system. The audit selected a sample inventory count performed by third party and agreed the inventory counts back to the third party records noting no exceptions. A physical inventory was not performed at December 31, 2021. Due to the COVID pandemic, there were unusual circumstances that precluded an annual physical inventory in 2021, due to the easy transmission of COVID-19, by breathing in air carrying droplets or aerosol particles that contain the SARS-CoV-2 virus when close to an infected person or in poorly ventilated spaces with infected persons. Noting there were no system changes to the inventory system during 2021, we relied on the prior year audits and internal control review of the inventory system to provide comfort for the Organization for reliance on the inventory usage for this FEMA claim. In addition to relying on past inventory documented audit controls, the Organization routinely reviews the supply expense generated from the inventory system.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-002 Information on the Federal Program: Federal Agency: Department of Homeland Security Assistance Listing No.: 97.036 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through: Illinois State Department of Health Pass-Through Award Number: PA-05-IL-4489-PW-01416(1753) Section III ? Federal Award Findings and Questioned Costs (continued) Pass-Through Award Period of Performance: January 20, 2020 through December 31, 2021 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?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).? Per the FEMA Project Worksheet Report #664845, under the Subgrant Conditions section, bullet point 1, ?As described in Title 2 Code of Federal Regulations (C.F.R.) ? 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.? Condition: The Organization?s internal controls were not suitably designed to retain all supporting documentation over their review and approval of FEMA federal expenditures. Management did not retain supporting documentation to support the inventory usage reports used in the development of the FEMA expenditures. Cause: Management designed a process to accumulate and review expenditures related to the FEMA; however, for certain components of the review and approval the supporting documentation was not retained to evidence that the internal review was sufficiently designed and operating effectively throughout the process. Section III ? Federal Award Findings and Questioned Costs (continued) Management did not retain supporting documentation to support the inventory usage reports used in the development of the FEMA expenditures. Questioned Costs: Unknown Context: The Organization recorded FEMA expenditures on the Schedule based on the number of units of the personal protective equipment (PPE) used during the period of performance outlined in the project worksheet times the average costs of each unit of PPE. The information used to develop the FEMA expenditures was obtained from the Organization?s inventory management system. Management did not retain supporting documentation to support the reliance on the inventory usage reports; therefore, the information from the inventory management system cannot be relied on for Uniform Guidance purposes. Management represented that they performed a review of FEMA expenditures but did not maintain evidence supporting all levels of review and approval of expenses under FEMA. We obtained the Organization?s FEMA project worksheet that reconciled to the schedule of expenditures of federal awards. We then selected a sample of 25 PPE items and agreed the items used and the average unit costs to the inventory management system. In addition, we compared the average unit cost to a third-party invoice to support the unit cost used. Management engaged a third party to perform a physical inventory of supplies at December 31, 2020 which included the PPE claimed in the SEFA obligation. The physical inventory was reconciled to the inventory management system. We selected a sample of inventory counts performed by the third-party agency and agreed the inventory counts back to the third-party records, noting no exceptions. A physical inventory was not performed at December 31, 2021. Total federal expenditures for Assistance Listing 97.036 recorded on the Schedule totaled $35,508,438 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Effect or Potential Effect: The amounts submitted for reimbursement and the reports submitted could be inaccurate or incomplete. Identification as a Repeat Finding, if Applicable: This is not a repeat finding. Recommendation: The Organization should design and implement internal controls that are sufficiently precise and require supporting documentation be retained over the review and approval of FEMA expenses. The Organization should retain evidence of internal controls related to access and change management over the report or a quality review process over the inventory reports. Management response: The FEMA personal protective equipment (PPE) claim covered two years, which are 2020 and 2021. As noted in the audit, the Organization engaged a third party to perform a physical inventory of supplies at December 31, 2020 which included the PPE claimed in the SEFA obligation. The physical inventory was reconciled to the inventory management system. The audit selected a sample inventory count performed by third party and agreed the inventory counts back to the third party records noting no exceptions. A physical inventory was not performed at December 31, 2021. Due to the COVID pandemic, there were unusual circumstances that precluded an annual physical inventory in 2021, due to the easy transmission of COVID-19, by breathing in air carrying droplets or aerosol particles that contain the SARS-CoV-2 virus when close to an infected person or in poorly ventilated spaces with infected persons. Noting there were no system changes to the inventory system during 2021, we relied on the prior year audits and internal control review of the inventory system to provide comfort for the Organization for reliance on the inventory usage for this FEMA claim. In addition to relying on past inventory documented audit controls, the Organization routinely reviews the supply expense generated from the inventory system.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.
Finding 2022-001 Information on the Federal Program: Federal Agency: United States Department of Health and Human Services Assistance Listing No.: Research and Development Cluster (various Assistance Listings) Award Periods: Various Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): The Uniform Guidance 2 CFR Section 200.303 states, ?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).? 45 CFR Part 75 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards, Appendix IX to Part 75 ? Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts with Hospitals, states: ?Charges for salaries and wages of individuals other than members of the professional staff will be supported by daily time and attendance and payroll distribution records. For members of the professional staff, current and reasonable estimates of the percentage distribution of their total effort may be used as support in the absence of actual time records. In order to qualify as current and reasonable, estimates must be made no later than one month (though not necessarily a calendar month) after the month in which the services were performed. Estimates determined before the performance of services, such as budget estimates on a monthly, quarterly, or yearly basis do not qualify as estimates of effort spent.? Section III ? Federal Award Findings and Questioned Costs (continued) Condition: Charges of salaries and wages to the R&D Cluster were not consistently reviewed by a knowledgeable individual or not certified timely. In addition, certain individuals? effort certification did not account for 100% of their effort (R&D and institutional). Cause: The Organization does have not internal controls in place to monitor that 100% of effort is certified, and the effort is certified timely and reviewed and approved by a knowledgeable individual. Effect or Potential Effect: Charges for salaries and wages were charged to the R&D Cluster for individuals who did not certify their effort or 100% of their effort. In addition, the lack of internal controls over the review and approval of effort certification could result in unallowable charges for salaries and wages to be charged to the program. Questioned Costs: None Context: We selected a sample of 40 salaries and wages totaling $68,789 for the year ended December 31, 2022. We concluded effort certifications did not include 100% effort and were not reviewed and approved for 20 selections ($40,817). We also noted one instance ($1,965) which was not reviewed and approved timely. Total salaries and wages, fringe benefits, and indirect costs related to the R&D Cluster were $2,786,348 for the year ended December 31, 2022. Total R&D expenditures recorded on the Schedule of Expenditures of Federal Awards (the Schedule) are $3,323,540 for the year ended December 31, 2022. Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a Repeat Finding, if Applicable: This is a repeat finding; see 2021-002. Recommendation: The Organization should implement internal controls to require individuals to certify 100% of their effort on a monthly basis to ensure that salaries and wages are based on actual efforts spent. The Organization should design and implement internal controls to review and approve the effort certified by an individual with knowledge of the employee?s effort on a timely basis. Management?s Response: The Office of Sponsored Research (OSR) committed in the 2020 Corrective Action Plan to implement a paper format effort certification process beginning March 2022. This process was fully implemented by the end of fiscal 2022. Also in 2022, Advocate Aurora Research Institute employees were transferred and integrated under one financial system. The integration of this system supports the monitoring of 100% of total effort. The OSR will also continue to utilize a paper effort certification process. The OSR team will generate effort certification form, distribute the effort certification form to the appropriate team member for manual or electronic signature and obtain a secondary approval signature from an individual who has first-hand knowledge of the team member?s activities. All completed effort certification forms will be verified and initialed by a third individual. Effort certification logs will be maintained to ensure that all effort certifications are completed within 30 days. Completed effort certification forms will be maintained within OSR.