Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(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 statutes, regulations, and the terms and conditions of the Federal award. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2024-001 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program: Research and Development Cluster Assistance Listing Number: 93.837 and 93.847 Criteria: Criteria: 2 CFR 200.332(b) requires pass-through entities to evaluate each subrecipient’s risk of non-compliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of 200.332. Further, 200.332(d) requires pass-through entities to monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Condition: Annually, BILH works with over 200 subrecipients in conducting its research activities. While Joslin Diabetes Center (the Center) has a subrecipient pre-award risk assessment process in place, for 5 of 9 subrecipients selected for testwork, we were unable to verify that the pre-award risk assessment procedures were fully performed. Additionally, while the Center’s risk assessment procedures correspond with a risk-based monitoring plan, for 8 of 9 subrecipients selected for testwork, we were unable to verify that the required monitoring activities were fully completed. We deemed this to be a significant deficiency in internal controls. Cause: As a result of turnover during the fiscal year within Research Finance there was a lack of effective operation of internal controls over subrecipient risk assessment and monitoring activities. Possible Asserted Effect: Without the proper operation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect non-compliance. 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 a repeat finding. (Prior year finding 2023-002) BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 Recommendation: We recommend that the Center evaluate its current Subrecipient Monitoring and Management Policy to ensure that the policy reflects each of the risk assessment and monitoring compliance requirements of the Uniform Guidance. Additionally, the results of the Center’s risk assessment and monitoring activities should be formally documented within the tracking log which should then be subject to formal review and approval by an appropriate individual within Research Finance. Views of Responsible Officials: Management acknowledges although tracking logs had been maintained, due to personnel turnover during the year, not all had been reviewed. Management has since created a shared email address to ensure communication and information sharing with all necessary parties. Management is reviewing its current policy for opportunities to strengthen internal controls and current procedures while utilizing available resources.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2024-001 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program: Research and Development Cluster Assistance Listing Number: 93.837 and 93.847 Criteria: Criteria: 2 CFR 200.332(b) requires pass-through entities to evaluate each subrecipient’s risk of non-compliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of 200.332. Further, 200.332(d) requires pass-through entities to monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Condition: Annually, BILH works with over 200 subrecipients in conducting its research activities. While Joslin Diabetes Center (the Center) has a subrecipient pre-award risk assessment process in place, for 5 of 9 subrecipients selected for testwork, we were unable to verify that the pre-award risk assessment procedures were fully performed. Additionally, while the Center’s risk assessment procedures correspond with a risk-based monitoring plan, for 8 of 9 subrecipients selected for testwork, we were unable to verify that the required monitoring activities were fully completed. We deemed this to be a significant deficiency in internal controls. Cause: As a result of turnover during the fiscal year within Research Finance there was a lack of effective operation of internal controls over subrecipient risk assessment and monitoring activities. Possible Asserted Effect: Without the proper operation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect non-compliance. 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 a repeat finding. (Prior year finding 2023-002) BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 Recommendation: We recommend that the Center evaluate its current Subrecipient Monitoring and Management Policy to ensure that the policy reflects each of the risk assessment and monitoring compliance requirements of the Uniform Guidance. Additionally, the results of the Center’s risk assessment and monitoring activities should be formally documented within the tracking log which should then be subject to formal review and approval by an appropriate individual within Research Finance. Views of Responsible Officials: Management acknowledges although tracking logs had been maintained, due to personnel turnover during the year, not all had been reviewed. Management has since created a shared email address to ensure communication and information sharing with all necessary parties. Management is reviewing its current policy for opportunities to strengthen internal controls and current procedures while utilizing available resources.
BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 (3) Findings and Questioned Costs Relating to Federal Awards Finding 2024-001 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program: Research and Development Cluster Assistance Listing Number: 93.837 and 93.847 Criteria: Criteria: 2 CFR 200.332(b) requires pass-through entities to evaluate each subrecipient’s risk of non-compliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of 200.332. Further, 200.332(d) requires pass-through entities to monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Condition: Annually, BILH works with over 200 subrecipients in conducting its research activities. While Joslin Diabetes Center (the Center) has a subrecipient pre-award risk assessment process in place, for 5 of 9 subrecipients selected for testwork, we were unable to verify that the pre-award risk assessment procedures were fully performed. Additionally, while the Center’s risk assessment procedures correspond with a risk-based monitoring plan, for 8 of 9 subrecipients selected for testwork, we were unable to verify that the required monitoring activities were fully completed. We deemed this to be a significant deficiency in internal controls. Cause: As a result of turnover during the fiscal year within Research Finance there was a lack of effective operation of internal controls over subrecipient risk assessment and monitoring activities. Possible Asserted Effect: Without the proper operation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect non-compliance. 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 a repeat finding. (Prior year finding 2023-002) BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES Schedule of Findings and Questioned Costs Year ended September 30, 2024 Recommendation: We recommend that the Center evaluate its current Subrecipient Monitoring and Management Policy to ensure that the policy reflects each of the risk assessment and monitoring compliance requirements of the Uniform Guidance. Additionally, the results of the Center’s risk assessment and monitoring activities should be formally documented within the tracking log which should then be subject to formal review and approval by an appropriate individual within Research Finance. Views of Responsible Officials: Management acknowledges although tracking logs had been maintained, due to personnel turnover during the year, not all had been reviewed. Management has since created a shared email address to ensure communication and information sharing with all necessary parties. Management is reviewing its current policy for opportunities to strengthen internal controls and current procedures while utilizing available resources.
Finding Number: 2024-006 Prior Year Finding Number: 2023-013 Compliance Requirement: Subrecipient Monitoring Program: U.S. Department of the Treasury COVID-19 - Homeowner Assistance Fund ALN: 21.026 Award #: Various Award Year: 10/01/2023 – 09/30/2024 Government Department/Agency: Department of Housing and Community Development (DHCD) 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. Additionally, 2 CFR Section 200.332 specifies that pass-through entities must evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. Based upon the pass-through entity's assessment of risk posed by the subrecipient, auditee management determined that onsite reviews of the subrecipient’s program operations were appropriate and designed the following control: DHCD performs desk audits, scheduled site visits and unscheduled site visits during the fiscal year. Reports are prepared at the site visits and properly documented. The reports include deficiencies, recommendations, and proposed corrective action and are reviewed and approved by the Project Managers, Program Managers, and Supervisory Program Managers. Condition – During our review of four (4) subrecipient samples from a total population of seven (7) subrecipients, we noted the following: • For one (1) subrecipient, DHCD provided plans to perform a review, but was unable to provide evidence of the review or a finalized report. • For three (3) subrecipients, DHCD neither performed an onsite review nor a desk audit. Questioned Costs – Not determinable. Context – This is a condition identified per review of DHCD’s compliance with the subrecipient monitoring requirements using a statistically valid sample. Effect – DHCD did not comply with the subrecipient monitoring requirements of the Homeowner Assistance Fund program. Cause – DHCD does not have fully effective internal controls over compliance with respect to the onsite review process. Recommendation – We recommend that DHCD strictly adhere to its policies and procedures to ensure that onsite reviews are properly performed and documented for subrecipients. Related Noncompliance – Material noncompliance. Views of Responsible Officials and Planned Corrective Actions – DHCD concurs 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.