Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Procurement and Suspension and Debarment: Identification of the Federal Program; Federal Agency and Program Name, Assistance Listing # : U.S. Department of Defense, National Aeronautics and Space Administration, National Science Foundation U.S Department of Treasury, U.S. Department of Health and Human Services, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement (RHC) 93.912 Research and Development Cluster (R&D) Various Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) Award Year: FY 2024 93.243 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: We noted the following matters during our testing of Procurement and Suspension and Debarment requirements: • For the New Vendor Setup process, we noted five instances out of 25 samples where the vendor screening for suspension and debarment was not performed prior to setting up the vendor in the system and procuring the goods/services. • Under the RHC program, for two of the three procurement transactions tested, we noted the requester and approver of the sole source justification form was the same individual. Cause: Sanford did not follow its policy and perform the vendor screening for suspension and debarment prior to setting up the vendor in the system. In addition, Sanford did not require a separate individual to approve the sole source justification forms. Effect or Potential Effect: By setting up the vendor in the system prior to performing the vendor screening for suspension and debarment, Sanford could have potentially entered into a business transaction with suspended or debarred parties and paid for those costs using federal grant funding. Sanford did not comply with its policy by having appropriate personnel, in addition to the requester, review and approve the sole source justification forms. Questioned Costs: $0 Context: Sanford follows a consistent vendor setup process for setting up each new vendor in the system, regardless of whether the vendor transactions are funded through federal grant funding or through other sources. To prevent a suspended or debarred vendor from being added as a new vendor, the vendor is checked against the suspension and debarment database electronically before completion of the vendor setup. We selected 25 new vendors that were set up in FY 2024 to verify that the suspension and debarment screening was performed prior to adding the vendors in the System and noted for five of these 25 vendors, the suspension and debarment screening was not performed prior to setting up the vendor in the system. Although Sanford’s policy was not followed, vendors that were not screened for suspension and debarment prior to transacting with them were not used for any of the major federal programs in FY 2024. Under the RHC program, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. Total procurement tested under the RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. The total federal expenditures for the RHC program for FY 2024 were $1,422,159. Identification as a Repeat Finding: Partial repeat finding of 2023–001. Recommendation: Management should strengthen its internal controls to ensure that the suspension and debarment screening is performed prior to adding the vendor in the System and entering into a business transaction with the vendor. Management should ensure that there is segregation of duties between the approver and requester of the sole source justification forms. Views of Responsible Officials: As it relates to the reliance on the third-party vendor that conducts suspension and debarment vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) report and, therefore, did not provide this level of report to Sanford. Prior to this year’s review, in November 2024, Sanford enhanced its operating procedures and began documenting a monthly validation of the suspension and debarment search results performed by the third-party vendor. These preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendors is effectively mitigated through existing preventive and detective internal controls. During the review, there were five instances out of 25 samples where suspension and debarment were not performed prior to vendor setup. None of those vendors were associated with the programs funded with federal funds. In addition, there were no instances where the suspension and debarment search was not performed after the enhanced operating procedures were implemented in November. As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of sole source procurement, the two transactions for which the requester and the approver of the sole source justification form was the same individual totaled $56,551. The total federal expenditures for the RHC program for the fiscal year ended December 31, 2024, were $1,422,159. Total procurement tested under RHC program was $77,209. Total population subject to procurement was $77,209, which represents 5.42% of the total federal expenditures under the RHC program. Sanford has revised its internal procedures to strengthen controls for sole source justification and documentation.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov. Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS. Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported. Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act. Questioned Costs: $0 Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act. Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Transparency Act Reporting: Identification of the Federal Program, Federal Agency and Program Name Assistance Listing #: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services Substance Abuse and Mental Health Services Projects of Regional and National Significance (SAMHSA Project) 93.243: Award Year(s): September 30, 2023–September 29, 2025 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov. Condition: We noted in one out of the three reports tested, the subaward amount and the subaward action date were inputted incorrectly in FSRS. Cause: Internal controls over review of the FFATA report prior to submission were not robust enough to prevent incorrect data elements reported. Effect or Potential Effect: Sanford did not appropriately report certain data elements in the FFATA report and consequently was not in compliance with the requirements under the Transparency Act. Questioned Costs: $0 Context: Under the SAMHSA project, there were three subrecipients that had a total of three subaward modifications in FY 2024. For one subaward for which the subaward amount and subaward action date were incorrect the total was $59,982. Total subrecipient’s costs are $228,216 in FY 2024. The total federal expenditures for the SAMHSA project for FY 2024 were $1,077,755. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend management strengthen its internal controls and procedures over the review of subrecipient awards and amendments to ensure the information submitted is accurate to be in compliance with the Federal Transparency Act. Views of Responsible Officials: As it relates to the Federal Funding Accountability and Transparency Act (FFATA) reporting, Sanford has revised procedures to provide further clarity on FFATA reporting. There is an additional requirement to include the FFATA report as an attachment to the subrecipient monitoring form, and this will be monitored through the monthly internal review conducted on subrecipient risk assessment and monitoring status.
Activities Allowed or Unallowed, Allowable Costs/Cost Principles: Identification of the Federal Program, Federal Agency and Program Name, Assistance Listing #:U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Pass Through Entity:West Virginia University, University of North Dakota R&D Cluster 93.859 Award Year(s): February 24, 2024–May 23, 2025 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR 200.303 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 and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: During our audit, we noted for five milestone invoices selected for testing, Sanford did not have documented evidence of review and approval of the study activities submitted to the pass-through entity. Cause: Management did not have sufficient internal controls to retain documentation over review and approval of milestone activities for allowability. Effect or Potential Effect: A lack of review and approval of milestone study activities could potentially result in unallowable activities being charged to the federal program. Questioned Costs: $0 Context: Total milestone grant amounts charged to the R&D Cluster were $390,061 in FY 2024. The total federal expenditures for the R&D Cluster for FY 2024 were $14,242,836. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend management document and retain support over the review and approval of milestone study activities. Views of Responsible Officials: As it relates to research milestone billing for the PASC grant, procedures have been revised. Upon receipt of invoice and payment from PASC, the Research Billing team will review and provide notification to the Research Director and Research Manager via email if the invoice and payment received matches to what is shown as owed in our systems.
Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Special Tests and Provisions Material Weakness in Internal Control Over Compliance Criteria – 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition – During our testing, we noted that the reserve account was not separately identified and there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program. Cause – The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked and a documented review and approval over the reserve fund occurred. Effect – The lack of adequate policies governing the review increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs – None reported. Context – Sampling was not used. The Organization has one reserve account that was tested. Repeat Finding from Prior Years – Yes, 2023-003 Recommendation – We recommend that the Organization enhance internal control policies to ensure that the reserve fund is separately tracked and formal documentation of reviews are present. View of Responsible Officials – Management agrees with the finding.
FINDING 2024-002 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listings Number: 21.027 Federal Award Number and Year (or Other Identifying Number): CY 2024 Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Condition and Context Prior to entering into subawards and covered transactions with the Coronavirus State and Local Fiscal Recovery Funds (SLFRF) awards funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include, but are not limited to, contracts for goods and services awarded under a nonprocurement transaction (e.g., grant agreement) that are expended to equal or exceed $25,000 and all subawards. The verification is to be done by checking the System for Award Management (SAM) Excluded Parties List System (EPLS), collecting a certification from the person or entity, or adding a clause or condition to the covered transaction with that person or entity. One covered transaction paid from SLFRF award funds during the audit period was identified and tested. The covered transaction, totaling $1,799,643, did not include the appropriate provisions in the contract, nor did the City require a certification or check the SAM EPLS to ensure the entity was not suspended or debarred prior to making payment. INDIANA STATE BOARD OF ACCOUNTS 15 CITY OF CROWN POINT SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Criteria 2 CFR 200.303 states in part: "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). . . ." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." Cause Management of the City did not have a formalized suspension and debarment policy to ensure procedures related to suspension and debarment were in place and followed. Effect Without the proper implementation of an effectively designed system of internal controls, the City could not ensure the vendors paid with federal funds were eligible to participate in federal programs. Any program funds the City used to pay vendors that have been suspended or debarred would be unallowable, and the funding agency could potentially recover them. Questioned Costs There were no questioned costs identified. Recommendation We recommended that the management of the City develop written policies and procedures to ensure its compliance with requirements related to suspension and debarment. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.
Department of Treasury Federal Financial Assistance Listing 21.033, Award 22ERP060843 Community Development Financial Institutions Equitable Recovery Program (CDFI ERP) Suspension & Debarment Significant Deficiency in Internal Control over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: In our testing of suspension and debarment, it was identified that there was no observable documentation to directly indicate that a search for suspension and debarment was performed for loans disbursed prior to entering into loan agreements. Cause: Meda does not have a formal process to search for suspension and debarment of entities prior to entering into a loan agreement. Effect: Failure to document the search for suspension and debarment before entering into the loan agreement could result in possibly noncompliance. Questioned Costs: None reported. Context: Two loans out of two tested accounted for $1,177,250 of the total expenses $2,094,298 charged to the federal award. Repeat Finding from Prior Years: Yes, 2023-002 Recommendation: We recommend that management add a formal process to search for suspension and department before entering into loan agreements. Views of Responsible Officials: Management agrees with the finding.
2024-002 Suspension and Debarment Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Significant Deficiency and Other Matter Federal Agency: U.S. Department of Health and Human Services Programs: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Award Number and Year: 242MN101S2514, 242MN101S2520, 242MN127Q7503; 2024 Pass-Through Agency: Minnesota Department of Human Services Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Federal requirements prohibit non-federal entities from contracting with or making subawards under covered transactions to parties that are suspended or debarred. Title 2 U.S. Code of Federal Regulations § 180.300 describes a required verification process. Prior to entering into the transaction, one of the following must be performed: (1) checking SAM.gov exclusions, (2) collecting a certification, or (3) adding a clause or condition to the covered transaction. Condition: For two of the four covered transactions tested, the County did not maintain documentation of verification that the vendors were not suspended or debarred prior to entering into the covered transactions. Questioned Costs: None. Context: The County entered into a total of 16 covered transactions during the year using State Administrative Matching Grants for the Supplemental Nutrition Assistance Program funds. The vendors tested that did not have documentation of verification prior to entering the transaction were not listed as suspended or debarred on SAM.gov at the time of the audit. The sample size was based on guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits. Effect: Failure to verify vendors are not suspended, debarred, or otherwise excluded prior to entering into a covered transaction may result in the County entering into a transaction with a vendor that is not authorized to provide goods and services under the grant. Cause: The County did not anticipate paying for these expenditures using federal funds and therefore did not perform or document the search for suspension and debarment. Recommendation: We recommend the County maintain documentation to demonstrate that vendors were not debarred, suspended or otherwise excluded from conducting business with the County; this documentation should be completed prior to entering into a covered transaction. View of Responsible Official: Concur
2024-002 Suspension and Debarment Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Significant Deficiency and Other Matter Federal Agency: U.S. Department of Health and Human Services Programs: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Award Number and Year: 242MN101S2514, 242MN101S2520, 242MN127Q7503; 2024 Pass-Through Agency: Minnesota Department of Human Services Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Federal requirements prohibit non-federal entities from contracting with or making subawards under covered transactions to parties that are suspended or debarred. Title 2 U.S. Code of Federal Regulations § 180.300 describes a required verification process. Prior to entering into the transaction, one of the following must be performed: (1) checking SAM.gov exclusions, (2) collecting a certification, or (3) adding a clause or condition to the covered transaction. Condition: For two of the four covered transactions tested, the County did not maintain documentation of verification that the vendors were not suspended or debarred prior to entering into the covered transactions. Questioned Costs: None. Context: The County entered into a total of 16 covered transactions during the year using State Administrative Matching Grants for the Supplemental Nutrition Assistance Program funds. The vendors tested that did not have documentation of verification prior to entering the transaction were not listed as suspended or debarred on SAM.gov at the time of the audit. The sample size was based on guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits. Effect: Failure to verify vendors are not suspended, debarred, or otherwise excluded prior to entering into a covered transaction may result in the County entering into a transaction with a vendor that is not authorized to provide goods and services under the grant. Cause: The County did not anticipate paying for these expenditures using federal funds and therefore did not perform or document the search for suspension and debarment. Recommendation: We recommend the County maintain documentation to demonstrate that vendors were not debarred, suspended or otherwise excluded from conducting business with the County; this documentation should be completed prior to entering into a covered transaction. View of Responsible Official: Concur
2024-002 Suspension and Debarment Prior Year Finding Number: N/A Year of Finding Origination: 2024 Type of Finding: Internal Control Over Compliance and Compliance Severity of Deficiency: Significant Deficiency and Other Matter Federal Agency: U.S. Department of Health and Human Services Programs: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Award Number and Year: 242MN101S2514, 242MN101S2520, 242MN127Q7503; 2024 Pass-Through Agency: Minnesota Department of Human Services Criteria: Title 2 U.S. Code of Federal Regulations § 200.303 states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Federal requirements prohibit non-federal entities from contracting with or making subawards under covered transactions to parties that are suspended or debarred. Title 2 U.S. Code of Federal Regulations § 180.300 describes a required verification process. Prior to entering into the transaction, one of the following must be performed: (1) checking SAM.gov exclusions, (2) collecting a certification, or (3) adding a clause or condition to the covered transaction. Condition: For two of the four covered transactions tested, the County did not maintain documentation of verification that the vendors were not suspended or debarred prior to entering into the covered transactions. Questioned Costs: None. Context: The County entered into a total of 16 covered transactions during the year using State Administrative Matching Grants for the Supplemental Nutrition Assistance Program funds. The vendors tested that did not have documentation of verification prior to entering the transaction were not listed as suspended or debarred on SAM.gov at the time of the audit. The sample size was based on guidance from Chapter 11 of the AICPA Audit Guide, Government Auditing Standards and Single Audits. Effect: Failure to verify vendors are not suspended, debarred, or otherwise excluded prior to entering into a covered transaction may result in the County entering into a transaction with a vendor that is not authorized to provide goods and services under the grant. Cause: The County did not anticipate paying for these expenditures using federal funds and therefore did not perform or document the search for suspension and debarment. Recommendation: We recommend the County maintain documentation to demonstrate that vendors were not debarred, suspended or otherwise excluded from conducting business with the County; this documentation should be completed prior to entering into a covered transaction. View of Responsible Official: Concur