BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Criteria: In accordance with 2 CFR section 200.313(b), a State must use, manage and dispose of equipment acquired under a Federal award by the State in accordance with State laws and procedures. SOP 216.1 and 216.6: • A physical inventory of the property must be taken and the results reconciled with the property records annually. SOP 215.1 and 215.2: • Adequate maintenance procedures must be developed to keep the property in good condition. Condition: Tests of equipment and real property noted the following: 1. CPA performed a capital assets inventory during fiscal year 2023. Based on controls testing, the worksheet of the count was approved by the Comptroller; however, it was not dated. 2. A reconciliation was not performed for FAA only assets which should be compared with accounting records. As such, the completeness and accuracy of program assets could not be determined. Total fixed asset additions capitalized and related to CPA’s major program, is as follows: Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Condition, continued: 3. Of fifteen items (or 17%) tested of a total population of eighty-eight FAA-funded capital assets, we noted deficiencies, as follows: a. One item (or 7%) has been unidentified, and management was not able to substantiate the existence of the actual fixed asset. This asset was cited in the prior year as a finding but was not corrected. As such, it is a repeat finding for FY2023. b. Seven items (or 47%) did not have any record or log of maintenance conducted during FY2023. No questioned costs are noted as we are unable to quantify the extent of the noncompliance. c. One item (or 7%) was improperly included on the fixed asset listing (asset number 000004). This asset was the original Crash, Fire, and Rescue (CFR) building constructed in 1970. The CFR building was demolished upon the construction of the Aircraft Rescue and Fire Fighting (ARFF) building in 1996. As such, this asset should have been noted as a disposal for FY2023. We present $0 questioned costs as no net book value was noted. Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Condition, continued: d. One item (or 7%) was improperly capitalized and included in the fixed asset listing (asset number 001504). This asset is the Master Plan Update for the Rota Airport. As this is a document pertaining to project deliverables and survey on airport assets, the Master Plan Update is not considered to be an actual fixed asset. We present $0 questioned costs for this asset as this is a matter of improper capitalization, and not an instance of an unallowable activity in the context of compliance. Cause: CPA lacks oversight responsibility and monitoring controls over compliance with equipment and real property management requirements. Effect: CPA is in noncompliance with applicable equipment and real property management requirements. No questioned costs are presented as we are unable to quantify the extent of noncompliance. Identification as a Repeat Finding: Finding 2022-003. Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Recommendation: CPA should reconcile the results of the annual physical inventory of the program’s assets to the property records and ascertain that the costs of the individual assets also agree to the records of accounting in terms of assets identified as additions or disposals for the year. Additionally, CPA should retain maintenance logs or equivalent documentation to show evidence of maintenance done on fixed assets and equipment. Lastly, CPA should implement and enforce proper procedures and criteria for capitalization of assets, based on the capitalization policy set by management to prevent improper capitalization. Views of Responsible Officials: Management states agreement with the finding. Refer to separate Corrective Action Plan.
Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Criteria: In accordance with 2 CFR section 200.313(b), a State must use, manage and dispose of equipment acquired under a Federal award by the State in accordance with State laws and procedures. SOP 216.1 and 216.6: • A physical inventory of the property must be taken and the results reconciled with the property records annually. SOP 215.1 and 215.2: • Adequate maintenance procedures must be developed to keep the property in good condition. Condition: Tests of equipment and real property noted the following: 1. CPA performed a capital assets inventory during fiscal year 2023. Based on controls testing, the worksheet of the count was approved by the Comptroller; however, it was not dated. 2. A reconciliation was not performed for FAA only assets which should be compared with accounting records. As such, the completeness and accuracy of program assets could not be determined. Total fixed asset additions capitalized and related to CPA’s major program, is as follows: Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Condition, continued: 3. Of fifteen items (or 17%) tested of a total population of eighty-eight FAA-funded capital assets, we noted deficiencies, as follows: a. One item (or 7%) has been unidentified, and management was not able to substantiate the existence of the actual fixed asset. This asset was cited in the prior year as a finding but was not corrected. As such, it is a repeat finding for FY2023. b. Seven items (or 47%) did not have any record or log of maintenance conducted during FY2023. No questioned costs are noted as we are unable to quantify the extent of the noncompliance. c. One item (or 7%) was improperly included on the fixed asset listing (asset number 000004). This asset was the original Crash, Fire, and Rescue (CFR) building constructed in 1970. The CFR building was demolished upon the construction of the Aircraft Rescue and Fire Fighting (ARFF) building in 1996. As such, this asset should have been noted as a disposal for FY2023. We present $0 questioned costs as no net book value was noted. Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Condition, continued: d. One item (or 7%) was improperly capitalized and included in the fixed asset listing (asset number 001504). This asset is the Master Plan Update for the Rota Airport. As this is a document pertaining to project deliverables and survey on airport assets, the Master Plan Update is not considered to be an actual fixed asset. We present $0 questioned costs for this asset as this is a matter of improper capitalization, and not an instance of an unallowable activity in the context of compliance. Cause: CPA lacks oversight responsibility and monitoring controls over compliance with equipment and real property management requirements. Effect: CPA is in noncompliance with applicable equipment and real property management requirements. No questioned costs are presented as we are unable to quantify the extent of noncompliance. Identification as a Repeat Finding: Finding 2022-003. Finding No.: 2023-003, continued Federal Agency: U.S. Department of Transportation AL Program: 20.106 Airport Improvement Program Federal Award Nos.: All AIP Grants Area: Equipment and Real Property Management Questioned Costs: $-0- Recommendation: CPA should reconcile the results of the annual physical inventory of the program’s assets to the property records and ascertain that the costs of the individual assets also agree to the records of accounting in terms of assets identified as additions or disposals for the year. Additionally, CPA should retain maintenance logs or equivalent documentation to show evidence of maintenance done on fixed assets and equipment. Lastly, CPA should implement and enforce proper procedures and criteria for capitalization of assets, based on the capitalization policy set by management to prevent improper capitalization. Views of Responsible Officials: Management states agreement with the finding. Refer to separate Corrective Action Plan.
2023-001: Internal Controls over Compliance and Compliance with Equipment and Real Property Management: Criteria or Specific Requirement – 2 CFR Part 200.313(d) outlines procedures for managing equipment (including replacement equipment whether acquired in whole or in part under a Federal award until disposition takes place). At a minimum, equipment and real property must meet the following requirements. (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award number under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition – During our testing of equipment and property inventory compliance, we identified six pieces of equipment totaling approximately $188,505 was not performed within the past two-years. Cause – Certain Foundation personnel did not comply with documented controls related to the physical inventory and reconciliation of property records for equipment to prevent noncompliance and the potential loss of equipment procured with Federal Funds. Effect or Potential Effect – The Foundation did not comply with 2 CFR Part 200.313. Failure to properly conduct an inventory of equipment can result in noncompliance and potential loss of equipment procured with the Federal funds. Questioned Costs – Not applicable as there were no questioned costs related to noncompliance. Context – This matter was identified through our testing of equipment records and disclosure by the Foundation of certain inventory items not being counted timely. BDO noted the equipment inventory population consists of approximately 2,800 items totaling approximately $85.5 million. Repeat Finding - This is a repeat finding from prior year. This was reported as finding 2022-001 in the 2022 report. Recommendation – We recommend that the Foundation comply with procedures to ensure compliance with 2 CFR Part 200.313 in relation to equipment and real property inventory procedures and maintenance of property records. Policies and procedures are already in place; therefore, personnel must implement those documented policies and procedures. Views of Responsible Officials and Planned Corrective Actions – Management agrees with this finding. Management is continuing several procedures to ensure equipment inventories are performed timely, incuding the review of inventory deficiency reports.
2023-001: Internal Controls over Compliance and Compliance with Equipment and Real Property Management: Criteria or Specific Requirement – 2 CFR Part 200.313(d) outlines procedures for managing equipment (including replacement equipment whether acquired in whole or in part under a Federal award until disposition takes place). At a minimum, equipment and real property must meet the following requirements. (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award number under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition – During our testing of equipment and property inventory compliance, we identified six pieces of equipment totaling approximately $188,505 was not performed within the past two-years. Cause – Certain Foundation personnel did not comply with documented controls related to the physical inventory and reconciliation of property records for equipment to prevent noncompliance and the potential loss of equipment procured with Federal Funds. Effect or Potential Effect – The Foundation did not comply with 2 CFR Part 200.313. Failure to properly conduct an inventory of equipment can result in noncompliance and potential loss of equipment procured with the Federal funds. Questioned Costs – Not applicable as there were no questioned costs related to noncompliance. Context – This matter was identified through our testing of equipment records and disclosure by the Foundation of certain inventory items not being counted timely. BDO noted the equipment inventory population consists of approximately 2,800 items totaling approximately $85.5 million. Repeat Finding - This is a repeat finding from prior year. This was reported as finding 2022-001 in the 2022 report. Recommendation – We recommend that the Foundation comply with procedures to ensure compliance with 2 CFR Part 200.313 in relation to equipment and real property inventory procedures and maintenance of property records. Policies and procedures are already in place; therefore, personnel must implement those documented policies and procedures. Views of Responsible Officials and Planned Corrective Actions – Management agrees with this finding. Management is continuing several procedures to ensure equipment inventories are performed timely, incuding the review of inventory deficiency reports.
2023-001: Internal Controls over Compliance and Compliance with Equipment and Real Property Management: Criteria or Specific Requirement – 2 CFR Part 200.313(d) outlines procedures for managing equipment (including replacement equipment whether acquired in whole or in part under a Federal award until disposition takes place). At a minimum, equipment and real property must meet the following requirements. (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award number under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition – During our testing of equipment and property inventory compliance, we identified six pieces of equipment totaling approximately $188,505 was not performed within the past two-years. Cause – Certain Foundation personnel did not comply with documented controls related to the physical inventory and reconciliation of property records for equipment to prevent noncompliance and the potential loss of equipment procured with Federal Funds. Effect or Potential Effect – The Foundation did not comply with 2 CFR Part 200.313. Failure to properly conduct an inventory of equipment can result in noncompliance and potential loss of equipment procured with the Federal funds. Questioned Costs – Not applicable as there were no questioned costs related to noncompliance. Context – This matter was identified through our testing of equipment records and disclosure by the Foundation of certain inventory items not being counted timely. BDO noted the equipment inventory population consists of approximately 2,800 items totaling approximately $85.5 million. Repeat Finding - This is a repeat finding from prior year. This was reported as finding 2022-001 in the 2022 report. Recommendation – We recommend that the Foundation comply with procedures to ensure compliance with 2 CFR Part 200.313 in relation to equipment and real property inventory procedures and maintenance of property records. Policies and procedures are already in place; therefore, personnel must implement those documented policies and procedures. Views of Responsible Officials and Planned Corrective Actions – Management agrees with this finding. Management is continuing several procedures to ensure equipment inventories are performed timely, incuding the review of inventory deficiency reports.
2023-001: Internal Controls over Compliance and Compliance with Equipment and Real Property Management: Criteria or Specific Requirement – 2 CFR Part 200.313(d) outlines procedures for managing equipment (including replacement equipment whether acquired in whole or in part under a Federal award until disposition takes place). At a minimum, equipment and real property must meet the following requirements. (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award number under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition – During our testing of equipment and property inventory compliance, we identified six pieces of equipment totaling approximately $188,505 was not performed within the past two-years. Cause – Certain Foundation personnel did not comply with documented controls related to the physical inventory and reconciliation of property records for equipment to prevent noncompliance and the potential loss of equipment procured with Federal Funds. Effect or Potential Effect – The Foundation did not comply with 2 CFR Part 200.313. Failure to properly conduct an inventory of equipment can result in noncompliance and potential loss of equipment procured with the Federal funds. Questioned Costs – Not applicable as there were no questioned costs related to noncompliance. Context – This matter was identified through our testing of equipment records and disclosure by the Foundation of certain inventory items not being counted timely. BDO noted the equipment inventory population consists of approximately 2,800 items totaling approximately $85.5 million. Repeat Finding - This is a repeat finding from prior year. This was reported as finding 2022-001 in the 2022 report. Recommendation – We recommend that the Foundation comply with procedures to ensure compliance with 2 CFR Part 200.313 in relation to equipment and real property inventory procedures and maintenance of property records. Policies and procedures are already in place; therefore, personnel must implement those documented policies and procedures. Views of Responsible Officials and Planned Corrective Actions – Management agrees with this finding. Management is continuing several procedures to ensure equipment inventories are performed timely, incuding the review of inventory deficiency reports.
2023-001: Internal Controls over Compliance and Compliance with Equipment and Real Property Management: Criteria or Specific Requirement – 2 CFR Part 200.313(d) outlines procedures for managing equipment (including replacement equipment whether acquired in whole or in part under a Federal award until disposition takes place). At a minimum, equipment and real property must meet the following requirements. (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award number under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition – During our testing of equipment and property inventory compliance, we identified six pieces of equipment totaling approximately $188,505 was not performed within the past two-years. Cause – Certain Foundation personnel did not comply with documented controls related to the physical inventory and reconciliation of property records for equipment to prevent noncompliance and the potential loss of equipment procured with Federal Funds. Effect or Potential Effect – The Foundation did not comply with 2 CFR Part 200.313. Failure to properly conduct an inventory of equipment can result in noncompliance and potential loss of equipment procured with the Federal funds. Questioned Costs – Not applicable as there were no questioned costs related to noncompliance. Context – This matter was identified through our testing of equipment records and disclosure by the Foundation of certain inventory items not being counted timely. BDO noted the equipment inventory population consists of approximately 2,800 items totaling approximately $85.5 million. Repeat Finding - This is a repeat finding from prior year. This was reported as finding 2022-001 in the 2022 report. Recommendation – We recommend that the Foundation comply with procedures to ensure compliance with 2 CFR Part 200.313 in relation to equipment and real property inventory procedures and maintenance of property records. Policies and procedures are already in place; therefore, personnel must implement those documented policies and procedures. Views of Responsible Officials and Planned Corrective Actions – Management agrees with this finding. Management is continuing several procedures to ensure equipment inventories are performed timely, incuding the review of inventory deficiency reports.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Federal Agency: U.S. Department of Transportation Federal Program Name: Highway Planning and Construction Assistance Listing Number: 20.205 Federal Award Identification Number and Year: Various Award Period: Various Type of Finding: Material Weakness in Internal Control over Compliance; Material Noncompliance (Modified Opinion) Criteria or specific requirement: Under 2 CFR 200.313 equipment acquired under a Federal award must be properly managed and proper records must be maintained. These records must contain information pertaining to Federal awards including description of property, serial number or other identification number, source of funding, title, acquisition date and cost of property, condition, ultimate disposition date including disposal, sales price and inventory. A physical inventory of the property must be taken and reconciled at least every two years, control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property, adequate maintenance procedures must be developed to keep the property in good conditions. Per 2 CFR Section 200.303(a) The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The County did not maintain accurate and updated equipment inventory listings for equipment purchased with Federal funds in accordance with 2 CFR 200.313. Questioned costs: None Context: The County’s equipment inventory listing of equipment purchased with grant funds was not maintained in a manner that complied with 2 CFR 200.313 during the year. An inventory listing that complied with 2 CFR 200.313 was prepared once it was requested during the audit. Additionally, for one of eight equipment items selected for testing from the inventory listing, the equipment serial number did not agree with the equipment inventory listing for that equipment’s location. Cause: The County did not have formal policies and procedures in place to manage and maintain equipment inventor records in compliance with 2 CFR 200.313. Effect: The County was not in compliance with the equipment compliance requirements of the program. Repeat Finding: No Recommendation: We recommend the County expand upon their capital asset inventory policies and procedures that are used for financial statement purposes to ensure that all equipment purchased with Federal funds are properly managed and maintained throughout the year to ensure all information, including the serial number and equipment location, is accurate and updated. We also recommend that the program personnel responsible for equipment records certify accuracy of the equipment records throughout the year. Views of responsible officials: Management agrees with the finding. See corrective action plan.
Finding 2023-001: Equipment and Real Property Management Program Name: National Railroad Passenger Corporation Grants COVID-19 National Railroad Passenger Corporation Grants Assistance Listing No. 20.315 Federal Award No.: FR-AMT-0020-20 FR-AMT-0023-21 FR-AMT-0028-22 69A36523504100AMTDC Federal Agency: U.S. Department of Transportation Criteria The code of federal regulations – 2 CFR 200.313 Equipment requires that: 1. Equipment must be used in the program or project for which it was acquired as long as needed, whether the project or program continues to be supported by the federal award or, when appropriate, under other Federal awards; however, the non Federal entity must not encumber the equipment without prior approval of the federal awarding agency (2 CFR 200.313(c) and (e)). 2. Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data, including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). 3. A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years (2 CFR 200.313(d)(2)). 4. A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR 200.313(d)(3)). Section II – Federal Awards Findings and Questioned Costs (continued) 5. Adequate maintenance procedures must be developed to keep the property in good condition (2 CFR 200.313(d)(4)). The code of federal regulations – 2 CFR 200.303 – Internal Controls requires that non-Federal entities must: 6. Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings (2 CFR 200.303(d)). 7. Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition We subjected 60 equipment assets to testing; these assets had a value of approximately $94.8 million. Of the $94.8 million, approximately $8.0 million were equipment assets purchased in previous years and were subject to our inventory observation testing and the remaining $86.8 million were equipment assets subject to both our purchases and inventory observation testing. Total acquisition cost of equipment assets within scope purchased during the year approximated $279.6 million. Net book value of all equipment purchased to date under grants within scope as of September 30, 2023 approximated $558.0 million. The following exceptions to the criteria were observed during the performance of the audit procedures: 1. For three of the equipment samples reviewed (approximately $0.3 million), it was observed that the assets did not have a unique asset identifier in the originally provided equipment population or did not have an asset identifier on the equipment. 2. For five of the equipment samples reviewed (approximately $0.5 million), it was observed that the condition data or location field in the asset records was blank. 3. During our procedures performed for two assets (approximately $1.1 million), we identified that no inventory had occurred for the assets, even though they had been placed in service over two years prior and would have required an inventory prior to our observation. As this came to our attention after the inventory was required and during our observation procedures, we investigated further and could not obtain alternative evidence to support that an inventory had occurred within the two-year period. 4. One of the equipment samples selected could not be located (approximately $0.05 million), as such we could not verify existence of the asset. 5. This is a repeat finding that has occurred over the last several audit periods. As such, Amtrak has not taken sufficient actions when instances of noncompliance are identified through audit findings to make necessary updates to their internal controls. Questioned Costs This finding resulted in a total of $0.05 million of likely questioned costs for Assistance Listing 20.315 – National Railroad Passenger Corporation Grant: FR-AMT-0028-22 This amount represents the amount per the purchase order for the asset in sub bullet #4 above that could not be located. Context We selected 60 equipment items for internal control and compliance testing of the above attributes. See condition section above for equipment amounts in both sample size and population. Effect Amtrak is not in compliance with the 2 CFR 200.313. Additionally, when assets are not accurately identified, it could lead to logistical inefficiencies as well as the difficulty in locating and identifying equipment timely. This may also put assets at greater risk of being lost, stolen, or not properly maintained. Cause The nature of much of Amtrak’s equipment is composed of moving assets that are on the tracks and operating up and down the corridors or around the yards or moving from location to location in a geographical region to achieve daily operational objectives. Furthermore, Amtrak resources are deployed such that managers and supervisors oversee geographical regions and equipment that are located throughout various routes that often connect through multiple states with many unmanned and less traveled stations. Asset locations, including changes on short notice for where the asset will be used, and frequent inspections occur in order to keep the equipment operating safely; however, the system of record is not always updated or updated in a timely manner to reflect the location and condition of the asset in the records upon a change in asset custody. Amtrak’s equipment policy, which is inconsistent with Uniform Guidance, currently requires that the condition field be confirmed and updated as part of the two-year inventory observation requirement. Section II – Federal Awards Findings and Questioned Costs (continued) In reviewing management’s controls, the key controls identified by management are not designed such that consistent and timely proactive monitoring and/or review occurs to ensure that an inventory occurs no less than once every two years. There is an identified control that stipulates “On a monthly basis, Capital Accounting will identify all equipment that has not been observed within 2 years and communicate to the Asset Management Team for action to be taken.” This control as designed is not preventive and may not identify the non-compliance risk until after non-compliance occurs. For the instances where the unique identifier did not exist on the asset or match the asset records, this was caused by a clerical/human error in recording the asset details in the system in addition to a lack of review control to verify the accuracy of the data recording. Identification as a Repeat Finding This finding is a repeat finding of 2022-001. Recommendation We recommend that Amtrak continue to work toward a full integration or reconciliation between Amtrak’s fixed asset system of record and the different equipment-tracking systems. We recommend that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs. For example, Amtrak should consider an automated system report that would flag an asset proactively when a 2-year inventory deadline is approaching. During the observation process, management should ensure there is a review control within the process to validate that the asset is accurately tagged and such identifying information matches the equipment-tracking system. Additionally, this review control should also be performed when the asset is first logged into the equipment-tracking system. In the interim, until such processes are fully implemented, Amtrak should enhance the current control procedures surrounding the asset documentation and ensure that field personnel are aware of and are consistently and carefully updating the asset records such that clerical/human errors are minimized and that the asset records contain the necessary asset details in order to properly track equipment by federal requirements. This would include enhancing the asset chain of custody recordkeeping so that such changes are identified and reported timely. Additionally, management should consider requiring the serial number and model number to be documented in the system of record at set up in addition to the asset tag number. This will help ensure that the equipment has a unique ID number that can help it be identified and matched to the system record should an asset number not get added timely. Finally, as it relates to condition #4 above, management should investigate the root cause of the asset that could not be located and determine if additional control changes or modifications need to be made in order to prevent reoccurrence. Views of Responsible Officials Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Since being created in 2022, Amtrak’s Enterprise Asset Management and Disposition team (EAMDT) has completed, with support from an outside consulting firm, a baseline assessment, as well as corrective action plans to specifically address noncompliance identified in the audit finding. Early in FY2024, Amtrak completed Phase 2 of this engagement to execute and implement a sub-set of these corrective action plans. Through this effort, EAMDT has prepared an updated Equipment Control Policy, developed standard operating procedures for equipment management, and developed a one-hour eLearning course that provides an overview of the importance for good equipment management practices and highlights the necessity for adhering to Single Audit compliance requirements of 2 CFR Part 200. The deliverables of this effort are to help ensure that assets are not capitalized without a complete record, which would include a unique asset identifier, as well as the condition and location of the assets. Additionally, EAMDT has developed reporting and analytics that enable both EAMDT and field personnel to be more proactive in managing the soon-to-be and out of compliance assets to both bring assets back into compliance, as well as to ensure an inventory is done and recorded within the two-year period. Lastly, EAMDT is working closely with Amtrak’s Digital Technology Department on the installation of location tracking technology on yard equipment and Engineering Maintenance of Way equipment, as well as developing an application that can be used on employee’s mobile devices to help ensure timely equipment assessments are completed.
Finding 2023-001: Equipment and Real Property Management Program Name: National Railroad Passenger Corporation Grants COVID-19 National Railroad Passenger Corporation Grants Assistance Listing No. 20.315 Federal Award No.: FR-AMT-0020-20 FR-AMT-0023-21 FR-AMT-0028-22 69A36523504100AMTDC Federal Agency: U.S. Department of Transportation Criteria The code of federal regulations – 2 CFR 200.313 Equipment requires that: 1. Equipment must be used in the program or project for which it was acquired as long as needed, whether the project or program continues to be supported by the federal award or, when appropriate, under other Federal awards; however, the non Federal entity must not encumber the equipment without prior approval of the federal awarding agency (2 CFR 200.313(c) and (e)). 2. Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data, including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). 3. A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years (2 CFR 200.313(d)(2)). 4. A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR 200.313(d)(3)). Section II – Federal Awards Findings and Questioned Costs (continued) 5. Adequate maintenance procedures must be developed to keep the property in good condition (2 CFR 200.313(d)(4)). The code of federal regulations – 2 CFR 200.303 – Internal Controls requires that non-Federal entities must: 6. Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings (2 CFR 200.303(d)). 7. Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition We subjected 60 equipment assets to testing; these assets had a value of approximately $94.8 million. Of the $94.8 million, approximately $8.0 million were equipment assets purchased in previous years and were subject to our inventory observation testing and the remaining $86.8 million were equipment assets subject to both our purchases and inventory observation testing. Total acquisition cost of equipment assets within scope purchased during the year approximated $279.6 million. Net book value of all equipment purchased to date under grants within scope as of September 30, 2023 approximated $558.0 million. The following exceptions to the criteria were observed during the performance of the audit procedures: 1. For three of the equipment samples reviewed (approximately $0.3 million), it was observed that the assets did not have a unique asset identifier in the originally provided equipment population or did not have an asset identifier on the equipment. 2. For five of the equipment samples reviewed (approximately $0.5 million), it was observed that the condition data or location field in the asset records was blank. 3. During our procedures performed for two assets (approximately $1.1 million), we identified that no inventory had occurred for the assets, even though they had been placed in service over two years prior and would have required an inventory prior to our observation. As this came to our attention after the inventory was required and during our observation procedures, we investigated further and could not obtain alternative evidence to support that an inventory had occurred within the two-year period. 4. One of the equipment samples selected could not be located (approximately $0.05 million), as such we could not verify existence of the asset. 5. This is a repeat finding that has occurred over the last several audit periods. As such, Amtrak has not taken sufficient actions when instances of noncompliance are identified through audit findings to make necessary updates to their internal controls. Questioned Costs This finding resulted in a total of $0.05 million of likely questioned costs for Assistance Listing 20.315 – National Railroad Passenger Corporation Grant: FR-AMT-0028-22 This amount represents the amount per the purchase order for the asset in sub bullet #4 above that could not be located. Context We selected 60 equipment items for internal control and compliance testing of the above attributes. See condition section above for equipment amounts in both sample size and population. Effect Amtrak is not in compliance with the 2 CFR 200.313. Additionally, when assets are not accurately identified, it could lead to logistical inefficiencies as well as the difficulty in locating and identifying equipment timely. This may also put assets at greater risk of being lost, stolen, or not properly maintained. Cause The nature of much of Amtrak’s equipment is composed of moving assets that are on the tracks and operating up and down the corridors or around the yards or moving from location to location in a geographical region to achieve daily operational objectives. Furthermore, Amtrak resources are deployed such that managers and supervisors oversee geographical regions and equipment that are located throughout various routes that often connect through multiple states with many unmanned and less traveled stations. Asset locations, including changes on short notice for where the asset will be used, and frequent inspections occur in order to keep the equipment operating safely; however, the system of record is not always updated or updated in a timely manner to reflect the location and condition of the asset in the records upon a change in asset custody. Amtrak’s equipment policy, which is inconsistent with Uniform Guidance, currently requires that the condition field be confirmed and updated as part of the two-year inventory observation requirement. Section II – Federal Awards Findings and Questioned Costs (continued) In reviewing management’s controls, the key controls identified by management are not designed such that consistent and timely proactive monitoring and/or review occurs to ensure that an inventory occurs no less than once every two years. There is an identified control that stipulates “On a monthly basis, Capital Accounting will identify all equipment that has not been observed within 2 years and communicate to the Asset Management Team for action to be taken.” This control as designed is not preventive and may not identify the non-compliance risk until after non-compliance occurs. For the instances where the unique identifier did not exist on the asset or match the asset records, this was caused by a clerical/human error in recording the asset details in the system in addition to a lack of review control to verify the accuracy of the data recording. Identification as a Repeat Finding This finding is a repeat finding of 2022-001. Recommendation We recommend that Amtrak continue to work toward a full integration or reconciliation between Amtrak’s fixed asset system of record and the different equipment-tracking systems. We recommend that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs. For example, Amtrak should consider an automated system report that would flag an asset proactively when a 2-year inventory deadline is approaching. During the observation process, management should ensure there is a review control within the process to validate that the asset is accurately tagged and such identifying information matches the equipment-tracking system. Additionally, this review control should also be performed when the asset is first logged into the equipment-tracking system. In the interim, until such processes are fully implemented, Amtrak should enhance the current control procedures surrounding the asset documentation and ensure that field personnel are aware of and are consistently and carefully updating the asset records such that clerical/human errors are minimized and that the asset records contain the necessary asset details in order to properly track equipment by federal requirements. This would include enhancing the asset chain of custody recordkeeping so that such changes are identified and reported timely. Additionally, management should consider requiring the serial number and model number to be documented in the system of record at set up in addition to the asset tag number. This will help ensure that the equipment has a unique ID number that can help it be identified and matched to the system record should an asset number not get added timely. Finally, as it relates to condition #4 above, management should investigate the root cause of the asset that could not be located and determine if additional control changes or modifications need to be made in order to prevent reoccurrence. Views of Responsible Officials Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Since being created in 2022, Amtrak’s Enterprise Asset Management and Disposition team (EAMDT) has completed, with support from an outside consulting firm, a baseline assessment, as well as corrective action plans to specifically address noncompliance identified in the audit finding. Early in FY2024, Amtrak completed Phase 2 of this engagement to execute and implement a sub-set of these corrective action plans. Through this effort, EAMDT has prepared an updated Equipment Control Policy, developed standard operating procedures for equipment management, and developed a one-hour eLearning course that provides an overview of the importance for good equipment management practices and highlights the necessity for adhering to Single Audit compliance requirements of 2 CFR Part 200. The deliverables of this effort are to help ensure that assets are not capitalized without a complete record, which would include a unique asset identifier, as well as the condition and location of the assets. Additionally, EAMDT has developed reporting and analytics that enable both EAMDT and field personnel to be more proactive in managing the soon-to-be and out of compliance assets to both bring assets back into compliance, as well as to ensure an inventory is done and recorded within the two-year period. Lastly, EAMDT is working closely with Amtrak’s Digital Technology Department on the installation of location tracking technology on yard equipment and Engineering Maintenance of Way equipment, as well as developing an application that can be used on employee’s mobile devices to help ensure timely equipment assessments are completed.
Finding 2023-002: Preparation and Maintenance of Equipment Population Program Name: National Railroad Passenger Corporation Grants COVID-19 National Railroad Passenger Corporation Grants Assistance Listing No. 20.315 Federal Award No.: FR-AMT-0020-20 FR-AMT-0022-21 FR-AMT-0026-22 FR-AMT-0028-22 Federal Agency: U.S. Department of Transportation Criteria The code of federal regulations – 2 CFR 200.1 provides the following definition of Equipment: - Equipment means tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds the lesser of the capitalization level established by the non-Federal entity for financial statement purposes, or $5,000. The code of federal regulations – 2 CFR 200.313 Equipment requires that: - Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data, including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). The code of federal regulations – 2 CFR 200.303 – Internal Controls requires that non-Federal entities must: - Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition The following exceptions to the criteria were observed during the performance of the audit procedures as it relates to completeness and accuracy of equipment population: 1. In reviewing the equipment population provided to EY as part of the audit for FY23, we noted the Company mapped FY23 equipment activity relating to FR-AMT-0020-20, FR-AMT-0022-21 and FR-AMT-0026-22 grants to older funding sources. Per inquiry of management, FY23 Overhauled equipment activity was originally mapped incorrectly to prior year grant awards and fund source years. 2. Population contained an asset that could not be observed as the nature of the purchased equipment was a combination of tools with each individually costing less than $5,000. 3. Population contained an asset that had been replaced in 2021, and as such should not have been included in the equipment listing. Questioned Costs None. Context Population of single audit equipment records is manually prepared each period where funding sources are assigned to each asset based on the unique asset identifier. The data source used by the Capital Accounting team did not take into consideration overhaul activity during the FY23 period that was undertaken over equipment assets acquired in 2014-2016 fiscal years. (Condition 1) One of the 60 selections made for testing could not be observed, as the underlying equipment maintenance systems did not have a record of this item due to the fact that items purchased consisted of tools that were individually less than $5,000 and as such did not meet the definition of Equipment as defined by 2 CFR 200.1. The population provided to EY incorrectly included an exception as described in the Condition section above, indicating that following internal control was not functioning as designed: “Monthly, Lead Accountant, Capital Accounting exports equipment data from PP into an Excel spreadsheet (the Equipment Spreadsheet) and manually determines the eligibility of the equipment. The determination is subsequently reviewed by the Senior Manager, Capital Accounting.” (Condition 2) In the initial population provided, we noted that one of the assets had been retired and replaced in 2021 and should have not been included within the population. This was an error that was not corrected during timely updates of the maintenance records. (Condition 3) Effect Amtrak’s control procedures in place as it relates to the preparation of equipment population were not designed in such a manner that would timely identify the conditions noted. Cause The exception from the criteria noted is attributed to the following cause: 1. Highly manual process required to reconcile data between multiple systems in order to maintain a complete and accurate record for each equipment asset. 2. Internal control procedures as designed are not detailed enough to review equipment purchases to be able to determine eligibility of the asset to be classified as equipment under 2 CFR equipment valuation thresholds. Identification as a Repeat Finding Not a repeat finding. Recommendation To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Views of Responsible Officials Amtrak agrees with the finding related to the equipment population and believes that strengthening procedures around the preparation and review of the population is needed to prevent errors in future populations. Amtrak recognizes that remediation of this finding will require enhancing documentation around the preparation of the population and documenting a set of procedures to follow for reviewing the population. Some of these efforts have already been enacted while others will be developed and implemented prior to September 30, 2024.
Finding 2023-002: Preparation and Maintenance of Equipment Population Program Name: National Railroad Passenger Corporation Grants COVID-19 National Railroad Passenger Corporation Grants Assistance Listing No. 20.315 Federal Award No.: FR-AMT-0020-20 FR-AMT-0022-21 FR-AMT-0026-22 FR-AMT-0028-22 Federal Agency: U.S. Department of Transportation Criteria The code of federal regulations – 2 CFR 200.1 provides the following definition of Equipment: - Equipment means tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds the lesser of the capitalization level established by the non-Federal entity for financial statement purposes, or $5,000. The code of federal regulations – 2 CFR 200.313 Equipment requires that: - Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data, including the date of disposal and sales price of the property (2 CFR 200.313(d)(1)). The code of federal regulations – 2 CFR 200.303 – Internal Controls requires that non-Federal entities must: - Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition The following exceptions to the criteria were observed during the performance of the audit procedures as it relates to completeness and accuracy of equipment population: 1. In reviewing the equipment population provided to EY as part of the audit for FY23, we noted the Company mapped FY23 equipment activity relating to FR-AMT-0020-20, FR-AMT-0022-21 and FR-AMT-0026-22 grants to older funding sources. Per inquiry of management, FY23 Overhauled equipment activity was originally mapped incorrectly to prior year grant awards and fund source years. 2. Population contained an asset that could not be observed as the nature of the purchased equipment was a combination of tools with each individually costing less than $5,000. 3. Population contained an asset that had been replaced in 2021, and as such should not have been included in the equipment listing. Questioned Costs None. Context Population of single audit equipment records is manually prepared each period where funding sources are assigned to each asset based on the unique asset identifier. The data source used by the Capital Accounting team did not take into consideration overhaul activity during the FY23 period that was undertaken over equipment assets acquired in 2014-2016 fiscal years. (Condition 1) One of the 60 selections made for testing could not be observed, as the underlying equipment maintenance systems did not have a record of this item due to the fact that items purchased consisted of tools that were individually less than $5,000 and as such did not meet the definition of Equipment as defined by 2 CFR 200.1. The population provided to EY incorrectly included an exception as described in the Condition section above, indicating that following internal control was not functioning as designed: “Monthly, Lead Accountant, Capital Accounting exports equipment data from PP into an Excel spreadsheet (the Equipment Spreadsheet) and manually determines the eligibility of the equipment. The determination is subsequently reviewed by the Senior Manager, Capital Accounting.” (Condition 2) In the initial population provided, we noted that one of the assets had been retired and replaced in 2021 and should have not been included within the population. This was an error that was not corrected during timely updates of the maintenance records. (Condition 3) Effect Amtrak’s control procedures in place as it relates to the preparation of equipment population were not designed in such a manner that would timely identify the conditions noted. Cause The exception from the criteria noted is attributed to the following cause: 1. Highly manual process required to reconcile data between multiple systems in order to maintain a complete and accurate record for each equipment asset. 2. Internal control procedures as designed are not detailed enough to review equipment purchases to be able to determine eligibility of the asset to be classified as equipment under 2 CFR equipment valuation thresholds. Identification as a Repeat Finding Not a repeat finding. Recommendation To address the Condition identified above, we recommend Amtrak to continue integration of the systems in such a way that appropriate funding source would be tagged to each asset automatically and that required property records would automatically be consolidated into one system of record and updated in that system. Ensure that adequate IT interface and business process application controls over the completeness, accuracy, validity, confidentiality, and availability of transactions and data during application processing (input, processing, output, etc.) are in place. Additionally, management should consider breaking out large purchase orders containing multiple items of equipment and tools under one purchase request, by creating separate level 2 WBSE codes in order to distinguish between different types of items being acquired, in order to be able to provide more appropriate classification. Views of Responsible Officials Amtrak agrees with the finding related to the equipment population and believes that strengthening procedures around the preparation and review of the population is needed to prevent errors in future populations. Amtrak recognizes that remediation of this finding will require enhancing documentation around the preparation of the population and documenting a set of procedures to follow for reviewing the population. Some of these efforts have already been enacted while others will be developed and implemented prior to September 30, 2024.
FINDING 2023-025 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626, Equipment and Real Property Management - Inaccurate Inventory of Equipment See Schedule of Findings and Questioned Costs for chart/table. Condition DNR did not properly account for its capitalized equipment acquired with federal funds. We noted DNR did not assign an equipment identification tag and record the capital equipment in its inventory system for 1 of 6 sampled equipment acquisitions. Criteria Federal regulation 2 CFR 200.313(b) requires the state agency to manage equipment acquired under a federal award by the state in accordance with state laws and procedures. The FMG (Part II, Chapter 21, Section 110) and DNR policy require DNR to tag all equipment and to maintain in its records the tag numbers of all capital assets. Cause DNR informed us the equipment was not tagged or included in its inventory system because of an oversight. Effect Insufficient capital asset records could increase the risk that equipment may be missing, lost, or stolen. The federal grantor agency could issue sanctions or disallowances related to noncompliance. Known Questioned Costs None. Recommendation We recommend DNR properly account for its capitalized equipment acquisitions. Management Views DNR agrees with the finding.
FINDING 2023-025 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626, Equipment and Real Property Management - Inaccurate Inventory of Equipment See Schedule of Findings and Questioned Costs for chart/table. Condition DNR did not properly account for its capitalized equipment acquired with federal funds. We noted DNR did not assign an equipment identification tag and record the capital equipment in its inventory system for 1 of 6 sampled equipment acquisitions. Criteria Federal regulation 2 CFR 200.313(b) requires the state agency to manage equipment acquired under a federal award by the state in accordance with state laws and procedures. The FMG (Part II, Chapter 21, Section 110) and DNR policy require DNR to tag all equipment and to maintain in its records the tag numbers of all capital assets. Cause DNR informed us the equipment was not tagged or included in its inventory system because of an oversight. Effect Insufficient capital asset records could increase the risk that equipment may be missing, lost, or stolen. The federal grantor agency could issue sanctions or disallowances related to noncompliance. Known Questioned Costs None. Recommendation We recommend DNR properly account for its capitalized equipment acquisitions. Management Views DNR agrees with the finding.
FINDING 2023-025 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626, Equipment and Real Property Management - Inaccurate Inventory of Equipment See Schedule of Findings and Questioned Costs for chart/table. Condition DNR did not properly account for its capitalized equipment acquired with federal funds. We noted DNR did not assign an equipment identification tag and record the capital equipment in its inventory system for 1 of 6 sampled equipment acquisitions. Criteria Federal regulation 2 CFR 200.313(b) requires the state agency to manage equipment acquired under a federal award by the state in accordance with state laws and procedures. The FMG (Part II, Chapter 21, Section 110) and DNR policy require DNR to tag all equipment and to maintain in its records the tag numbers of all capital assets. Cause DNR informed us the equipment was not tagged or included in its inventory system because of an oversight. Effect Insufficient capital asset records could increase the risk that equipment may be missing, lost, or stolen. The federal grantor agency could issue sanctions or disallowances related to noncompliance. Known Questioned Costs None. Recommendation We recommend DNR properly account for its capitalized equipment acquisitions. Management Views DNR agrees with the finding.
FINDING 2023-025 Fish and Wildlife Cluster, ALN 15.605, 15.611, and 15.626, Equipment and Real Property Management - Inaccurate Inventory of Equipment See Schedule of Findings and Questioned Costs for chart/table. Condition DNR did not properly account for its capitalized equipment acquired with federal funds. We noted DNR did not assign an equipment identification tag and record the capital equipment in its inventory system for 1 of 6 sampled equipment acquisitions. Criteria Federal regulation 2 CFR 200.313(b) requires the state agency to manage equipment acquired under a federal award by the state in accordance with state laws and procedures. The FMG (Part II, Chapter 21, Section 110) and DNR policy require DNR to tag all equipment and to maintain in its records the tag numbers of all capital assets. Cause DNR informed us the equipment was not tagged or included in its inventory system because of an oversight. Effect Insufficient capital asset records could increase the risk that equipment may be missing, lost, or stolen. The federal grantor agency could issue sanctions or disallowances related to noncompliance. Known Questioned Costs None. Recommendation We recommend DNR properly account for its capitalized equipment acquisitions. Management Views DNR agrees with the finding.
Federal Aid Policies Finding 2023-002 Condition: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. Criteria: The 2 CFR 200 requires the adoption of federal aid policies and that they are to be updated and maintained in accordance with the federal regulations. These policies include the following along with the 2 CFR 200 reference. a. Cash Management Procedure –200.302(b)(6) and 200.305 b. Cost Allowability Procedures –200.302(b)(7) c. Conflicts of Interest Policy –200.318(c) d. Procurement Procedures –200.318(a) and 200.319(d) e. Method for Conducting Technical Evaluations of Proposals and Selecting Recipients –200.320(b)(2)(ii) f. Travel Policy –200.475(a) g. Procedures for Managing Equipment –200.313(d) h. Employee Benefits –200.431 Cause: The Authority has experienced a high turnover of employees since 2021 when the policies were adopted and have not been reviewed since their adoption. Effect: The Authority is noncompliant with 2 CFR 200. Directive: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Management’s Response--Corrective Action Plan: Contact person is Rufus Adams, Executive Director, 275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward.
Federal Aid Policies Finding 2023-002 Condition: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. Criteria: The 2 CFR 200 requires the adoption of federal aid policies and that they are to be updated and maintained in accordance with the federal regulations. These policies include the following along with the 2 CFR 200 reference. a. Cash Management Procedure –200.302(b)(6) and 200.305 b. Cost Allowability Procedures –200.302(b)(7) c. Conflicts of Interest Policy –200.318(c) d. Procurement Procedures –200.318(a) and 200.319(d) e. Method for Conducting Technical Evaluations of Proposals and Selecting Recipients –200.320(b)(2)(ii) f. Travel Policy –200.475(a) g. Procedures for Managing Equipment –200.313(d) h. Employee Benefits –200.431 Cause: The Authority has experienced a high turnover of employees since 2021 when the policies were adopted and have not been reviewed since their adoption. Effect: The Authority is noncompliant with 2 CFR 200. Directive: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Management’s Response--Corrective Action Plan: Contact person is Rufus Adams, Executive Director, 275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward.
Federal Aid Policies Finding 2023-002 Condition: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. Criteria: The 2 CFR 200 requires the adoption of federal aid policies and that they are to be updated and maintained in accordance with the federal regulations. These policies include the following along with the 2 CFR 200 reference. a. Cash Management Procedure –200.302(b)(6) and 200.305 b. Cost Allowability Procedures –200.302(b)(7) c. Conflicts of Interest Policy –200.318(c) d. Procurement Procedures –200.318(a) and 200.319(d) e. Method for Conducting Technical Evaluations of Proposals and Selecting Recipients –200.320(b)(2)(ii) f. Travel Policy –200.475(a) g. Procedures for Managing Equipment –200.313(d) h. Employee Benefits –200.431 Cause: The Authority has experienced a high turnover of employees since 2021 when the policies were adopted and have not been reviewed since their adoption. Effect: The Authority is noncompliant with 2 CFR 200. Directive: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Management’s Response--Corrective Action Plan: Contact person is Rufus Adams, Executive Director, 275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward.
Federal Aid Policies Finding 2023-002 Condition: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. Criteria: The 2 CFR 200 requires the adoption of federal aid policies and that they are to be updated and maintained in accordance with the federal regulations. These policies include the following along with the 2 CFR 200 reference. a. Cash Management Procedure –200.302(b)(6) and 200.305 b. Cost Allowability Procedures –200.302(b)(7) c. Conflicts of Interest Policy –200.318(c) d. Procurement Procedures –200.318(a) and 200.319(d) e. Method for Conducting Technical Evaluations of Proposals and Selecting Recipients –200.320(b)(2)(ii) f. Travel Policy –200.475(a) g. Procedures for Managing Equipment –200.313(d) h. Employee Benefits –200.431 Cause: The Authority has experienced a high turnover of employees since 2021 when the policies were adopted and have not been reviewed since their adoption. Effect: The Authority is noncompliant with 2 CFR 200. Directive: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Management’s Response--Corrective Action Plan: Contact person is Rufus Adams, Executive Director, 275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward.
Federal Aid Policies Finding 2023-002 Condition: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. Criteria: The 2 CFR 200 requires the adoption of federal aid policies and that they are to be updated and maintained in accordance with the federal regulations. These policies include the following along with the 2 CFR 200 reference. a. Cash Management Procedure –200.302(b)(6) and 200.305 b. Cost Allowability Procedures –200.302(b)(7) c. Conflicts of Interest Policy –200.318(c) d. Procurement Procedures –200.318(a) and 200.319(d) e. Method for Conducting Technical Evaluations of Proposals and Selecting Recipients –200.320(b)(2)(ii) f. Travel Policy –200.475(a) g. Procedures for Managing Equipment –200.313(d) h. Employee Benefits –200.431 Cause: The Authority has experienced a high turnover of employees since 2021 when the policies were adopted and have not been reviewed since their adoption. Effect: The Authority is noncompliant with 2 CFR 200. Directive: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Management’s Response--Corrective Action Plan: Contact person is Rufus Adams, Executive Director, 275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward.
Finding Number: 2023-016 Prior Year Finding Number: 2022-007 Compliance Requirement: Equipment and Real Property Management Program: Government Department/Agency: U.S. Department of Education COVID-19 – Education Stabilization Fund Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D Award #: S425D210034 Award Year: 05/07/2020 – 09/30/2023 COVID-19 – Education Stabilization Fund American Rescue Plan - Elementary and Secondary Schools Emergency Relief Fund (ARP-ESSER) ALN: 84.425U Award #: S425U210034-21A Award Year: 03/24/2021 – 09/30/2023 District of Columbia Public Schools (DCPS) Criteria - The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards (i.e., auditee management) establish and maintain internal control designed to reasonably ensure compliance with Federal statues, regulations, and the terms and conditions of the Federal award. Also, a physical inventory of the property must be taken and the results reconciled with the property records at least once every two years (2 CFR section 200.313(d)(2)). Condition – We noted that there is no formally documented physical count for equipment purchased using federal funds in 2023. Questioned Costs – Not determinable. Context – This is a condition identified per review of DCPS’ compliance with the specified requirements using a statistically valid sample. Effect – There is a risk that a lack of physical count could lead to misappropriation of assets and noncompliance with Federal regulations resulting in a return of Federal awards received. Cause – Due to a lack of formal process and policy regarding physical count, DCPS was unable to adequately support compliance with its policies and procedures regarding monitoring of equipment acquired with Federal funds. Recommendation – We recommend that DCPS implement policies, procedures and controls that will ensure that equipment counts are conducted, that evidence of a count is formally documented and an authorized individual formally approves the result of the count and the related reconciliation to equipment records, in order to adhere to Federal regulations related to equipment and its related maintenance. Related Noncompliance – Noncompliance. Views of Responsible Officials and Planned Corrective Actions – DCPS agrees with the conditions and recommendations of this finding. The District’s corrective action is described in the Management’s Corrective Action Plan included as Appendix B of the attached Management’s Section.
Finding Number: 2023-016 Prior Year Finding Number: 2022-007 Compliance Requirement: Equipment and Real Property Management Program: Government Department/Agency: U.S. Department of Education COVID-19 – Education Stabilization Fund Elementary and Secondary School Emergency Relief (ESSER) Fund ALN: 84.425D Award #: S425D210034 Award Year: 05/07/2020 – 09/30/2023 COVID-19 – Education Stabilization Fund American Rescue Plan - Elementary and Secondary Schools Emergency Relief Fund (ARP-ESSER) ALN: 84.425U Award #: S425U210034-21A Award Year: 03/24/2021 – 09/30/2023 District of Columbia Public Schools (DCPS) Criteria - The Uniform Guidance in 2 CFR Section 200.303 requires that non-Federal entities receiving Federal awards (i.e., auditee management) establish and maintain internal control designed to reasonably ensure compliance with Federal statues, regulations, and the terms and conditions of the Federal award. Also, a physical inventory of the property must be taken and the results reconciled with the property records at least once every two years (2 CFR section 200.313(d)(2)). Condition – We noted that there is no formally documented physical count for equipment purchased using federal funds in 2023. Questioned Costs – Not determinable. Context – This is a condition identified per review of DCPS’ compliance with the specified requirements using a statistically valid sample. Effect – There is a risk that a lack of physical count could lead to misappropriation of assets and noncompliance with Federal regulations resulting in a return of Federal awards received. Cause – Due to a lack of formal process and policy regarding physical count, DCPS was unable to adequately support compliance with its policies and procedures regarding monitoring of equipment acquired with Federal funds. Recommendation – We recommend that DCPS implement policies, procedures and controls that will ensure that equipment counts are conducted, that evidence of a count is formally documented and an authorized individual formally approves the result of the count and the related reconciliation to equipment records, in order to adhere to Federal regulations related to equipment and its related maintenance. Related Noncompliance – Noncompliance. Views of Responsible Officials and Planned Corrective Actions – DCPS agrees with the conditions and recommendations of this finding. The District’s corrective action is described in the Management’s Corrective Action Plan included as Appendix B of the attached Management’s Section.
Item 2023‐002 – Equipment and Real Property Management Education Stabilization Fund (ESF) ALN# 84.425 U.S. Department of Education Passed through the State Department of Education Grant period – Year ended September 30, 2023 (84.425U) (84.425D) Criteria – Grantees should have controls in place to ensure that all capital equipment or improvements to land, building, or equipment that were purchased with grant funds received prior approval prior to encumbrance of the expenditure. 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.313 and 2 CFR 200.439 requires that the following rules of allow ability must apply to equipment and other capital expenditures “Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or pass‐through entity.” Condition – Adequate controls were not in place to ensure that prior approval for capital expenditures for equipment acquisition or improvements to land, buildings, or equipment was obtained prior to incurring the expenditure. Cause – Certain Capital Equipment and improvements to building expenditures were not included in the approved budget to grantor. There was a lack of sufficient controls over the review of capital expenditures to ensure that they were included in the approved budget. Effect – Lack of approval over equipment and capital improvements could lead to disallowed costs. We noted that certain equipment and improvement projects were not included in approved budget for ESSER Funds. Questioned Costs – $33,716 Recommendation – We recommend the strengthening of controls to ensure that proper approval is received prior to the acquisition of improvements to land, building or equipment. Management’s Response – The Board will strengthen the controls in place to provide assurance that proper approval is obtained from grantor agency prior to the purchase of equipment and real property.
Item 2023‐002 – Equipment and Real Property Management Education Stabilization Fund (ESF) ALN# 84.425 U.S. Department of Education Passed through the State Department of Education Grant period – Year ended September 30, 2023 (84.425U) (84.425D) Criteria – Grantees should have controls in place to ensure that all capital equipment or improvements to land, building, or equipment that were purchased with grant funds received prior approval prior to encumbrance of the expenditure. 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” 2 CFR 200.313 and 2 CFR 200.439 requires that the following rules of allow ability must apply to equipment and other capital expenditures “Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or pass‐through entity.” Condition – Adequate controls were not in place to ensure that prior approval for capital expenditures for equipment acquisition or improvements to land, buildings, or equipment was obtained prior to incurring the expenditure. Cause – Certain Capital Equipment and improvements to building expenditures were not included in the approved budget to grantor. There was a lack of sufficient controls over the review of capital expenditures to ensure that they were included in the approved budget. Effect – Lack of approval over equipment and capital improvements could lead to disallowed costs. We noted that certain equipment and improvement projects were not included in approved budget for ESSER Funds. Questioned Costs – $33,716 Recommendation – We recommend the strengthening of controls to ensure that proper approval is received prior to the acquisition of improvements to land, building or equipment. Management’s Response – The Board will strengthen the controls in place to provide assurance that proper approval is obtained from grantor agency prior to the purchase of equipment and real property.
Criteria: Non federal entities other than states must follow 2 CFR sections 200.313(c) through (e) which require that property records must be maintained and include various information including, but not limited to, a description of the property, a serial number or identification number, the location, use and condition of the property, and any ultimate disposition data including the date of disposal (2 CFR section 200.313(d)(1). Further, 2 CFR section 200.313(d)(2) required that a physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years. When original or replacement equipment acquired under a federal award is no longer needed for a federal program, the non federal entity must request disposition instructions from the federal awarding agency if required by the terms and conditions of the award. Title 2 U.S. Code of Federal Regulations Part 200 (2CFR 200) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, section 303(a) states, the non Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non Federal entity is managing the Federal award in compliance with Federal statues, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: 40 items of equipment were selected from all equipment acquired under federal awards from Lifespan’s property records and were physically inspected for safeguarding and proper maintenance. Of the 40 items selected, we noted 4 items could not be located by Lifespan or evidence that the items were properly disposed could not be provided in accordance with the requirements outlined above. Possible Asserted Cause and Effect: In each of the four instances, Lifespan did not follow appropriate processes, procedures and internal controls to timely and appropriately maintain accurate equipment records. Identification of Questioned Costs: Not determinable. Whether Sampling was Statistically Valid: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend that Lifespan review its current policies and procedures to ensure that equipment acquired under federal awards is appropriately inventoried and records are updated to ensure compliance with federal regulations. Views of Responsible Officials: Lifespan agrees with the finding as departments did not consistently follow its equipment tracking, storage, and disposal policies and procedures related to equipment purchased with federal funding. The following steps will be taken to address the finding: All departments of Lifespan will receive a notice from the Office of Research Administration that equipment tags, proper storage, and timely disposal of equipment are an integral part of the internal control process for capital assets. The Office of Research Administration communication will be sent to all impacted departments by July 15, 2024 and office hours will be made available for any departments that have questions. Contact: Lifespan Office of Research Administration: Daniel Bryant, Director Research Operations 401-444-6893. DBryant@lifespan.org Mindy Marshall, Director Grants and Contracts 401-444-4487. MMarshall6@lifespan.org Leslie Simone, Research Information Systems 401-444-8696. LVarone@lifespan.org. Expected Implementation: July 15, 2024
Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance) Significant Deficiency Criteria: Uniform Guidance 2 CFR, Part §200.313(a) requires that non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 40 transactions for internal controls over compliance. 2 of the 40 transactions examined did not contain sufficient evidence that a review and approval process was completed prior to payment being processed. Questioned Costs: None Cause: The Coalition does not have sufficiently established control policies and procedures to ensure proper approvals are obtained prior to the disbursement transactions being processed. Effect: Disbursements are being processed without proper approval, resulting in the possibility of disallowed expenditures. Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.313(a) and establishes appropriate internal control policies and procedures and that all staff be trained on those policies and procedures, so they are familiar with the requirements. We further recommend the Coalition does not process payment for disbursements that do not contain necessary approvals. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.
Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance) Significant Deficiency Criteria: Uniform Guidance 2 CFR, Part §200.313(a) requires that non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 40 transactions for internal controls over compliance. 2 of the 40 transactions examined did not contain sufficient evidence that a review and approval process was completed prior to payment being processed. Questioned Costs: None Cause: The Coalition does not have sufficiently established control policies and procedures to ensure proper approvals are obtained prior to the disbursement transactions being processed. Effect: Disbursements are being processed without proper approval, resulting in the possibility of disallowed expenditures. Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.313(a) and establishes appropriate internal control policies and procedures and that all staff be trained on those policies and procedures, so they are familiar with the requirements. We further recommend the Coalition does not process payment for disbursements that do not contain necessary approvals. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.
Finding 2023 – 003: Activities Allowed/Unallowed and Cost Principles (Internal Control Over Compliance) Significant Deficiency ALN 20.509 Formula Grants for Rural Areas Criteria: Uniform Guidance 2 CFR, §200.313(a) requires that non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our review of Yankton Transit Inc.’s internal controls related to formula grants for rural areas major program, we tested 40 disbursements for control deficiencies and 40 transactions to support the opinion on compliance. Of the 40 transactions tested for control deficiencies, Yankton Transit Inc. did not have appropriate control documentation for at least 2 of the 40 transactions. Although support was found for Point-of-Sale transactions, there was no evidence of approval of the transactions. Of the 40 transactions tested to support the opinion on compliance, 0 transactions were out of compliance. Questioned Costs: None Cause: Yankton Transit Inc.’s current policies do not address the specific procedures related to processing POS transactions prior to the transactions being processed. Effect: Disbursements are being processed without proper approval, resulting in the possibility of disallowed expenditures. Recommendation: We recommend Yankton Transit Inc. become familiar with requirements of 2 CFR, §200.313(a) and establish appropriate internal control policies and procedures and that all staff be trained on those policies and procedures, so they are familiar with the requirements. We further recommend Yankton Transit Inc. does not process payments for disbursements that do not contain necessary approval of purchases. Views of Responsible Officials: See the corrective action plan that accompanies the schedule of findings and questioned costs.
2023-005 — Equipment and Real Property Management Federal/state program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination ALN: 93.441 Award period: 10/1/2022 – 9/30/2023 Criteria: 2 CFR section 200.313 requires that (1) equipment be used in the program or project for which it was acquired as long as needed, (2) property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, and cost of the property, and (3) a physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. Additionally, CBNHC’s Financial Policies and Procedures require a physical inventory of property be taken annually and reconciled to the general ledger. Condition: CBNHC has not completed a physical inventory of property and equipment in the last two years. Context: N/A Questioned Costs: None. Cause: CBNHC was significantly impacted by the COVID-19 pandemic. Additionally, CBNHC is not implementing their Financial Policies and Procedures to ensure that a physical inventory has been taken annually and reconciled to the general ledger. Effect: CBNHC is not in compliance with equipment and real property management requirements for the Indian Self-Determination program. Auditor’s Recommendations: CBNHC should implement its Financial Policies and Procedures and plan a physical inventory of its property as quickly as possible. The results of the physical inventory should be reconciled to the general ledger. Management’s Response: CBNHC did not have the adequate financial or administrative staff to perform a physical inventory and therefore has not been keeping with its Financial Policies and Procedures and performing an annual physical inventory.
2023-005 — Equipment and Real Property Management Federal/state program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination ALN: 93.441 Award period: 10/1/2022 – 9/30/2023 Criteria: 2 CFR section 200.313 requires that (1) equipment be used in the program or project for which it was acquired as long as needed, (2) property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, and cost of the property, and (3) a physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. Additionally, CBNHC’s Financial Policies and Procedures require a physical inventory of property be taken annually and reconciled to the general ledger. Condition: CBNHC has not completed a physical inventory of property and equipment in the last two years. Context: N/A Questioned Costs: None. Cause: CBNHC was significantly impacted by the COVID-19 pandemic. Additionally, CBNHC is not implementing their Financial Policies and Procedures to ensure that a physical inventory has been taken annually and reconciled to the general ledger. Effect: CBNHC is not in compliance with equipment and real property management requirements for the Indian Self-Determination program. Auditor’s Recommendations: CBNHC should implement its Financial Policies and Procedures and plan a physical inventory of its property as quickly as possible. The results of the physical inventory should be reconciled to the general ledger. Management’s Response: CBNHC did not have the adequate financial or administrative staff to perform a physical inventory and therefore has not been keeping with its Financial Policies and Procedures and performing an annual physical inventory.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2023 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2023-001 Federal Agency: United States Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing Number: Various Criteria: According to 2 CFR 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property, who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Per 2 CFR 200.313/(d)(3) and (4), a control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of property and adequate maintenance procedures must be developed to keep the property in good condition. Additionally, 2 CFR section 200.313(d)(2) requires a physical inventory of Federally acquired property must be taken and the results reconciled with the property records at least once every two years. In addition, 2 CFR 200.303 requires nonfederal entities to, among other things, establish and maintain effective internal control over 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. Effective internal controls should include procedures to ensure that accurate property records are maintained and equipment items are property tagged. Condition: Beth Israel Deaconess Medical Center (BIDMC), one of Beth Israel Lahey Health, Inc.’s affiliates, did not consistently follow its property management policies and procedures related to maintaining accurate property management records for equipment purchased with Federal R&D Cluster program awards. BIDMC conducts research at multiple locations throughout its campus where equipment purchased with Federal awards is utilized and maintained. As of September 30, 2023, BIDMC maintained Federally acquired property of approximately $65.5 million. BIDMC identifies all equipment in its property management records with individually assigned asset numbers and each individual asset record includes the specific location of the asset, the Federal award general ledger account number which funded the purchase of the asset, and other required information. An asset tag with the assigned asset number is affixed to each asset in accordance with BIDMC policy. BIDMC is required to safeguard equipment purchased with Federal awards, maintain current property records, and to perform a physical inventory of equipment purchased with Federal awards on a biennial basis. During our physical inspection of 40 pieces of equipment (with a cost basis of $4,562,717) purchased with Federal funds, we identified 7 items (with cost basis totaling $116,831) selected for physical observation which had not been tagged. Overall, BIDMC’s inventory listing included 34 pieces of equipment (with a cost basis of $1,500,686) acquired with Federal funds that were not tagged. Additionally, we noted that BIDMC did not conduct a physical inventory within the biennial period required. We deemed this to be a material weakness in internal controls. Cause: In discussing these conditions with BILH management, they stated the implementation of a new asset tagging system resulted in delayed tagging of purchased equipment as well as the physical inventory of Federally acquired property. Possible Asserted Effect: Failure to maintain accurate property records may prohibit BIDMC from properly safeguarding and maintaining equipment. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Identification of Whether the Audit Finding was a Repeat Finding: This is not a repeat finding. Recommendation: We recommend BIDMC review its procedures for updating property records to ensure they accurately reflect equipment information. Additionally, management should arrange for a physical inspection and reconciliation of Federally acquired property to books and records. Views of Responsible Officials: A review of the Beth Israel Deaconess Medical Center’s (BIDMC) property records maintenance revealed incomplete biennial physical inventory and incomplete tagging of new equipment purchased on federal awards. Management agrees with the recommendation and will update the asset tagging system to support completing the biennial inventory and resume tagging new equipment according to established policy.