Audit 5957

2023-002 Procurement, Suspension and Debarment Federal Grantor: Department of Health and Human Services and Department of Defense Program: Research and Development Cluster Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development Assistance Listing Number: 93.853, 12.420 Award Year: 7/1/2022 - 6/30/2023 Award Number: 1-DP2-NS-111996-01, W81XWH2010901 Pass-through Entity: Not applicable Pass-through Number: Not applicable Criteria Per 2 CFR section 180.220, non-federal entities are prohibited from contracting with or making subawards under covered transactions, where vendor purchases exceed $25,000, to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction, the non-federal entity must verify that the vendor is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at SAM.gov, (2) collecting a certification from the Vendor, or (3) adding a clause or condition to the covered transaction with that Vendor. University’s policies mirror the procurement policies as required by the Federal government, and defines a covered transaction as purchases exceeding $10,000. Condition In testing compliance with the suspension and debarment compliance requirement, 2 instances of 25 samples selected for testing were noted where the only evidence available to support the date of the performance of the required suspension and debarment checks was after the transaction date, as shown in the chart below. This is a repeat of prior year finding 2022-002. [table] Cause There are no questioned costs associated with this finding.The University uses Visual Compliance (VC) for suspension and debarment checks, which was implemented in 2019. Vendors onboarded prior to the implementation were registered and checked via a separate manual process within the procurement department. The above vendors were on-boarded and checked prior to the VC implementation; however, management could not provide evidence that the vendor check was performed prior to conducting business with the vendor due to the manual nature of the legacy process. Management has subsequently performed checks on these vendors and retained documentation of the checks to validate that the vendors are not currently suspended or debarred. Effect If procedures related to vendor suspended and debarred checks are not performed timely, there is a risk that the purchases could be made with a suspended or debarred vendor. Questioned Costs There are no questioned costs associated with this finding. Recommendation We recommend the University continue to follow its corrective action plan. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.

2023-001 Eligibility Federal Grantor: Department of Health and Human Services, Health Resources and Services Administration (“HRSA”) Pass-through Entity: City of Philadelphia, AIDS Activity Coordinating Office (“AACO”) Assistance Listing Title: HIV Emergency Relief Project Grants – Outpatient/Ambulatory Medical Care Assistance Listing Number: 93.914 Award Year: 2023 Award Number: RW2965 Pass-through Number: 2120575-01 Criteria Per the Ryan White Client Certification Form Instructions provided to management by the AIDS Activity Coordinating Office, “The certification process must begin for all clients upon initial intake for services and final eligibility is determined once all supporting documentation has been received and verified.” Additionally, the form states that copy of all documentation are to be retained by the provider. The City of Philadelphia Subrecipient Audit Guide Section 6130.04 provides a list of documents to be maintained and states “case management service providers are required to keep a file on each client served.” Further, per the Universal Monitoring Standards set forth by HRSA, the Ryan White HIV/AIDS Program Part A and B Monitoring Standards require service providers who receive Ryan White funding to screen to certify eligibility for Ryan White-funded services. The guidance states that documentation of eligibility determination is required in client records, as evidenced by copies of documents. Condition We reviewed a sample of 65 program participants to verify eligibility during the fiscal year. Of the 65 selected, there were 6 program participants at the Wood Clinic within the Clinical Care Associates of the University of Pennsylvania Health System (“Health System”) in which the Health System did not maintain Ryan White certification cards as documentation evidencing the control in place to certify the verification of the program participant’s eligibility. However, for all 6 program participants, the Health System provided records to support that the program participant met the eligibility requirements. Cause Management of the Health System noted that the AACO program at the Wood Clinic ended in November 2022 and the individuals involved in the process did not maintain the documentation evidencing that management verified participant eligibility in the program. Effect Program participants accepted into the program may be ineligible and the Health System may not be able to demonstrate eligibility of the participants. Questioned Costs None Recommendation The Health System should ensure that all individuals involved in the Ryan White certification process are educated that documentation is required to be maintained to support verification of program participant eligibility. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.

2023-002 Procurement, Suspension and Debarment Federal Grantor: Department of Health and Human Services and Department of Defense Program: Research and Development Cluster Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development Assistance Listing Number: 93.853, 12.420 Award Year: 7/1/2022 - 6/30/2023 Award Number: 1-DP2-NS-111996-01, W81XWH2010901 Pass-through Entity: Not applicable Pass-through Number: Not applicable Criteria Per 2 CFR section 180.220, non-federal entities are prohibited from contracting with or making subawards under covered transactions, where vendor purchases exceed $25,000, to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction, the non-federal entity must verify that the vendor is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at SAM.gov, (2) collecting a certification from the Vendor, or (3) adding a clause or condition to the covered transaction with that Vendor. University’s policies mirror the procurement policies as required by the Federal government, and defines a covered transaction as purchases exceeding $10,000. Condition In testing compliance with the suspension and debarment compliance requirement, 2 instances of 25 samples selected for testing were noted where the only evidence available to support the date of the performance of the required suspension and debarment checks was after the transaction date, as shown in the chart below. This is a repeat of prior year finding 2022-002. [table] Cause There are no questioned costs associated with this finding.The University uses Visual Compliance (VC) for suspension and debarment checks, which was implemented in 2019. Vendors onboarded prior to the implementation were registered and checked via a separate manual process within the procurement department. The above vendors were on-boarded and checked prior to the VC implementation; however, management could not provide evidence that the vendor check was performed prior to conducting business with the vendor due to the manual nature of the legacy process. Management has subsequently performed checks on these vendors and retained documentation of the checks to validate that the vendors are not currently suspended or debarred. Effect If procedures related to vendor suspended and debarred checks are not performed timely, there is a risk that the purchases could be made with a suspended or debarred vendor. Questioned Costs There are no questioned costs associated with this finding. Recommendation We recommend the University continue to follow its corrective action plan. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.

2023-002 Procurement, Suspension and Debarment Federal Grantor: Department of Health and Human Services and Department of Defense Program: Research and Development Cluster Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development Assistance Listing Number: 93.853, 12.420 Award Year: 7/1/2022 - 6/30/2023 Award Number: 1-DP2-NS-111996-01, W81XWH2010901 Pass-through Entity: Not applicable Pass-through Number: Not applicable Criteria Per 2 CFR section 180.220, non-federal entities are prohibited from contracting with or making subawards under covered transactions, where vendor purchases exceed $25,000, to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction, the non-federal entity must verify that the vendor is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at SAM.gov, (2) collecting a certification from the Vendor, or (3) adding a clause or condition to the covered transaction with that Vendor. University’s policies mirror the procurement policies as required by the Federal government, and defines a covered transaction as purchases exceeding $10,000. Condition In testing compliance with the suspension and debarment compliance requirement, 2 instances of 25 samples selected for testing were noted where the only evidence available to support the date of the performance of the required suspension and debarment checks was after the transaction date, as shown in the chart below. This is a repeat of prior year finding 2022-002. [table] Cause There are no questioned costs associated with this finding.The University uses Visual Compliance (VC) for suspension and debarment checks, which was implemented in 2019. Vendors onboarded prior to the implementation were registered and checked via a separate manual process within the procurement department. The above vendors were on-boarded and checked prior to the VC implementation; however, management could not provide evidence that the vendor check was performed prior to conducting business with the vendor due to the manual nature of the legacy process. Management has subsequently performed checks on these vendors and retained documentation of the checks to validate that the vendors are not currently suspended or debarred. Effect If procedures related to vendor suspended and debarred checks are not performed timely, there is a risk that the purchases could be made with a suspended or debarred vendor. Questioned Costs There are no questioned costs associated with this finding. Recommendation We recommend the University continue to follow its corrective action plan. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.

2023-001 Eligibility Federal Grantor: Department of Health and Human Services, Health Resources and Services Administration (“HRSA”) Pass-through Entity: City of Philadelphia, AIDS Activity Coordinating Office (“AACO”) Assistance Listing Title: HIV Emergency Relief Project Grants – Outpatient/Ambulatory Medical Care Assistance Listing Number: 93.914 Award Year: 2023 Award Number: RW2965 Pass-through Number: 2120575-01 Criteria Per the Ryan White Client Certification Form Instructions provided to management by the AIDS Activity Coordinating Office, “The certification process must begin for all clients upon initial intake for services and final eligibility is determined once all supporting documentation has been received and verified.” Additionally, the form states that copy of all documentation are to be retained by the provider. The City of Philadelphia Subrecipient Audit Guide Section 6130.04 provides a list of documents to be maintained and states “case management service providers are required to keep a file on each client served.” Further, per the Universal Monitoring Standards set forth by HRSA, the Ryan White HIV/AIDS Program Part A and B Monitoring Standards require service providers who receive Ryan White funding to screen to certify eligibility for Ryan White-funded services. The guidance states that documentation of eligibility determination is required in client records, as evidenced by copies of documents. Condition We reviewed a sample of 65 program participants to verify eligibility during the fiscal year. Of the 65 selected, there were 6 program participants at the Wood Clinic within the Clinical Care Associates of the University of Pennsylvania Health System (“Health System”) in which the Health System did not maintain Ryan White certification cards as documentation evidencing the control in place to certify the verification of the program participant’s eligibility. However, for all 6 program participants, the Health System provided records to support that the program participant met the eligibility requirements. Cause Management of the Health System noted that the AACO program at the Wood Clinic ended in November 2022 and the individuals involved in the process did not maintain the documentation evidencing that management verified participant eligibility in the program. Effect Program participants accepted into the program may be ineligible and the Health System may not be able to demonstrate eligibility of the participants. Questioned Costs None Recommendation The Health System should ensure that all individuals involved in the Ryan White certification process are educated that documentation is required to be maintained to support verification of program participant eligibility. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.

2023-002 Procurement, Suspension and Debarment Federal Grantor: Department of Health and Human Services and Department of Defense Program: Research and Development Cluster Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders; Military Medical Research and Development Assistance Listing Number: 93.853, 12.420 Award Year: 7/1/2022 - 6/30/2023 Award Number: 1-DP2-NS-111996-01, W81XWH2010901 Pass-through Entity: Not applicable Pass-through Number: Not applicable Criteria Per 2 CFR section 180.220, non-federal entities are prohibited from contracting with or making subawards under covered transactions, where vendor purchases exceed $25,000, to parties that are suspended or debarred. When a non-federal entity enters into a covered transaction, the non-federal entity must verify that the vendor is not suspended or debarred or otherwise excluded from participating in the transaction. This verification may be accomplished by (1) checking the System for Award Management (SAM) Exclusions maintained by the General Services Administration (GSA) and available at SAM.gov, (2) collecting a certification from the Vendor, or (3) adding a clause or condition to the covered transaction with that Vendor. University’s policies mirror the procurement policies as required by the Federal government, and defines a covered transaction as purchases exceeding $10,000. Condition In testing compliance with the suspension and debarment compliance requirement, 2 instances of 25 samples selected for testing were noted where the only evidence available to support the date of the performance of the required suspension and debarment checks was after the transaction date, as shown in the chart below. This is a repeat of prior year finding 2022-002. [table] Cause There are no questioned costs associated with this finding.The University uses Visual Compliance (VC) for suspension and debarment checks, which was implemented in 2019. Vendors onboarded prior to the implementation were registered and checked via a separate manual process within the procurement department. The above vendors were on-boarded and checked prior to the VC implementation; however, management could not provide evidence that the vendor check was performed prior to conducting business with the vendor due to the manual nature of the legacy process. Management has subsequently performed checks on these vendors and retained documentation of the checks to validate that the vendors are not currently suspended or debarred. Effect If procedures related to vendor suspended and debarred checks are not performed timely, there is a risk that the purchases could be made with a suspended or debarred vendor. Questioned Costs There are no questioned costs associated with this finding. Recommendation We recommend the University continue to follow its corrective action plan. Management’s View and Corrective Action Plan Management’s view and corrective action plan is included at the end of this report.