Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that 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).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.